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The purpose of this article is to introduce a novel way of keeping efficient surgical records by creating a sketch of both the pathology and treatment at the time of the surgery. This method of documentation has proven so convenient in the subsequent management of patients in a wide variety of situations that the concept of visual documentation is being presented for consideration. After a brief introduction to the unique history of its origin, a series of cases is offered to emphasize a few of the practical advantages of having a visual source for quick and accurate reference during the patient care process. The article will then conclude with a brief discussion of alternative methods of illustrative record keeping available.
In the early 1990s, I encountered a series of significant problems related to the inaccuracy of orthopaedic residents' operative dictations, both because of what they had just seen and what they felt were important to document about the surgery. This problem was highlighted by a deposition I gave as an expert witness regarding a patient for whom I had provided revision ACL surgery. There was a particularly awkward moment when an astute attorney noted that my description of the case varied significantly from the dictated note and that the understanding of the diagnosis seemed to have changed over the course of subsequent outpatient clinic notes. I was able to prove that the dictated notes contained obvious errors of both omission and commission that did not even coincide with the pre- or postoperative radiographic findings. This epiphany led me to a personal experiment wherein I decided to sketch what I understood to be the pertinent pathology of a surgical case, as well as what was done to correct it. I also listed the details which were important to recognize about each case.
After accumulating this detail in approximately 55 cases, I compared the residents' dictated surgery notes to my own “professorial truth” sketches. While the results were never formally published, every Iowa resident since then has heard of the results of this comparison—nearly 50% of the time there was at least one mistake (minor or major) in the operative dictation even though it was dictated immediately after the case. So many of the basics and details were so different from what I had documented in my sketches that one could wonder whether the trainee and I were scrubbed into the same cases that day. Since then, it has been my personal goal to create a brief sketch of each procedure before the patient leaves the operating room. This sketch becomes part of the medical record after it is recorded on the flip side of a brief operative note. More recently, the sketches have been scanned directly into the electronic medical record.
Over time, I have come to rely on these illustrations so heavily that I make it a habit to view them either before a patient visit, or while we are in the exam room, so that both the resident physicians and the patients can learn from seeing the sketch. I often find that without this reference I cannot recall the details that might prove critically important to maximizing the success of the treatment plan.
If my 1990s deposition experience was unnerving, a close look at the fundamental mistakes cropping up in multiple clinic dictations during prolonged treatment and complicated cases is even more impressive. Quickly referring to an illustration allows me to immediately understand exactly what was wrong, what was done about it, and keep on target with what is most important about the postoperative management plan.
A twenty-five year-old woman was referred for revision of an old, failed ACL reconstruction and possible OATS procedure to the medial femoral condyle (MFC). She had a defect which had been documented and mi-crofractured at the time of arthroscopy by her referring physician some 8 weeks previously.
At surgery, the MFC defect displayed encouraging results from the microfracture drilling performed by the referring surgeon. The original technical problem was an obvious misplacement of the femoral tunnel too far anterior and at 12:00. An accessory medial portal was employed to create a completely new femoral tunnel at the 1:30-2:00 position. The location of the original tibial tunnel was a bit anterior but close enough that posteriorizing that original tunnel was performed. This eliminated the effectiveness of available screw fixation placed within the tibial tunnel. Therefore, a screw and post combined with a spiked staple was used to secure the tibial fixation.
The key to postsurgical management was to be protection of the medial femoral condyle chondral defect (which came into contact with the tibial surface at around 45 degrees of flexion). However, the patient did not do well from the beginning. Her main problem was an impressive lack of motion. Postoperatively, she had not only been noncompliant with non-weight-bearing instructions, she had also not worked on her range of motion and could only demonstrate a range from 10-70 degrees of flexion. The dilemma was, “What can we do about the stiffness, and what are we specifically concerned about regarding the chondral area of concern?”
The operative drawing revealed a limited area of concern on the medial femoral condyle which centered around 45 degrees. Compression against the tibial surface in any other general range of motion was not of concern.
Therefore, the patient was sent back to physical therapy with instructions for the therapist to perform active assistive range of motion with the warning to the patient that we would have to manipulate her knee if she did not improve over the next four weeks. While progress was made in physical therapy, we did manipulate her knee at six weeks after the index surgery. Full recovery soon followed with the aid of vigorous therapy and with no problems from the cartilage defect which had been encountered.
A patient was seen in the outpatient clinic at six weeks after surgery. They had had a knee dislocation requiring extensive reconstructive surgery. Their current complaint was of severely restricted motion due to the extensive brace they wore. The brace was a long- leg brace complete with a footplate in neutral rotation but with free ankle motion in the saggital plane. The resident not only reported that the patient was anxious to be free of the brace but also questioned why the brace was used in the first place since he had never seen this type before.
Reference to the illustration quickly put things into perspective for both the resident and me. A close look at the details showed that the main reason for the extensive brace protection was the original laxity in every direction. However, in the author's experience, the most concern focused on protecting the knee from varus stress as well as excessive external rotation stress (reverse pivot shift). It was of particular note that the reverse pivot was persistent after the PCL was stabilized intra-operatively and before the posterior lateral sling procedure was performed. The fact that preoperative application of the brace with the footplate brought stability meant that protection of the more vulnerable parts of the surgical reconstruction was effective.
Despite the patient's request, the brace was continued until healing of the fibular head took place.
A 38-year-old entrepreneur mechanic underwent an arthroscopic medial menisectomy as well as a peripheral lateral meniscus repair located at the popliteal foramen six weeks ago. He was restricted to walking with a hinged knee brace locked straight and then actively flexing only to 90 degrees. His goal was to return to work as soon as possible in order to keep his business going. His major concern was that even in the brace, he experienced weight-bearing pain “deep” on the medial side of his knee. Maximum flexion also still produced posterolateral discomfort when the knee was flexed to 110 degrees.
Looking at the diagram and seeing chondromalacia on the medial and not the lateral side of his knee was revealing. A specific attempt to load his knee into varus throughout a functional range from 10-50 degrees produced medial discomfort. A similar attempt to load the lateral side brought relief.
A G-II unloader brace was trialed successfully.
The plan was for him to work on gradually increasing his range of motion at the lateral repair site. He was also to wear the unloader brace at his return to work. The remote possibility of his needing an opening wedge proximal tibial osteotomy was mentioned for reference, and to put the long-term use of the brace into proper perspective.
Two 17-year-old soccer players underwent distal transfer of the patellar tendon and MPFL reconstruction because of recurrent patellar dislocations. They became acquainted during rehabilitation, and both were anxiously competing to return to their sport as soon as possible. At four months post surgery, Case 4 appeared to be progressing quite well with sport-specific drills while Case 5 was progressing very slowly with basic development of quadriceps muscle strength. Routine examination for range of motion and strength revealed no differences between the two patients.
Referring to the surgical illustrations pointed to differences in the health of the patella in Case 5. A careful repeat history followed by re-examination for Case 5 revealed: a) anterior knee pain with activity; b) compression of the patella with the knee flexed 40 degrees was uncomfortable; and c) there was fine but audible crepitus present with one-legged squat past 45 degrees.
Plan: Case 4 was allowed to progress as tolerated. Case 5 was made aware of the problem of chondromalacia by pressing on the patella with the knee flexed 40 degrees. They are also warned of possible limitations of activity level in the future.
A 40-year-old male presented with catching and locking of the lateral aspect of the left knee. Given the acute onset of the symptoms, arthroscopy was performed. Arthroscopy demonstrated severe articular surface damage to the tibial surface not seen on MRI in addition to a complex medial meniscus tear with severe tibial chondral surface damage beneath it.
The patient did well for a brief time post surgery but developed increasing general pain when he resumed the demands of his manual labor job. After failed NSAIDs followed by Synvisc injections, an unloader brace trial was successful in the clinic. While the brace proved to be successful for activities of daily living, it was not quite sufficiently successful to allow a return to work. Long-leg standing films demonstrated that the weight-bearing line traversed through the lateral compartment. A closing wedge, proximal tibial osteotomy was performed that brought the alignment barely into the medial compartment.
A 20-year-old woman was operated on six weeks ago and was quite distressed that she was not relieved of all her symptoms. She had originally been seen for a second opinion because of dramatically increased pain after an arthroscopic plica excision and lateral release by an outside surgeon, performed because of chronic anterior knee pain.
A quick glance at the illustration reminded the medical team that this was the patient who displayed a grossly palpable plica as well as a medially dislocatable patella at preoperative examination. The presence of the plica played a role in the decision to perform an extensive plicectomy under direct visualization afforded by a limited arthrotomy, in addition to reconstruction of the LPFL with a semitendonosis allograft.
The patient's concerns were addressed by a) demonstrating the pathology and treatment in the sketch; b) pointing out the newly regained patellar stability; and c) reiterating the lack of the previously palpable plica tissue. She was reassured that great progress had already been made and that because there was no chondromalacia under the patella, a full recovery was anticipated. Full recovery was actually realized by the next visit.
I was away in New Orleans at a national meeting. My assistant informed me that the mother in a prominent family had just called requesting advice about her 15-year-old son. He had the opportunity to join a traveling soccer club team. However, the sign-up deadline was in the next few days if he did not want to give up his invitation to the next player on the waiting list.
At my request, my assistant e-mailed the illustration of the procedure as well as a copy of the last clinic note.
While the surgery was complex, sufficient progress had indeed been made to approve of this patient's return to action. By incorporating The Art ofArthroscopy into my practice, the degree of detail that I habitually included in each illustration allowed me to provide a quick as well as confident response.
We were in the middle of an extremely busy clinic and were informed that we had fallen behind in the schedule to the point that patients were complaining of waiting time. In an attempt to speed things up, the resident attempted to cut corners on a return patient by merely looking at the last outpatient clinic note. His routine exam failed to reveal any tenderness or limitation of motion and strength seemed adequate. His recommendation was that, at eight weeks after meniscus repair, the patient should be granted her wish to begin conditioning for upcoming volleyball tryouts.
A quick glance at the illustration quickly reminded me that this was a patient who was initially seen as a second opinion. She had been told elsewhere that her arthroscopy demonstrated a normal knee except for some mild softening of the lateral tibial plateau. While the chondromalacia was confirmed, it was secondary to the peripheral tear of the lateral meniscus at the popliteal foramen. Armed with this knowledge, the reexamination revealed signs of incomplete healing due to reproduction of posterior lateral pain with flexion to 120 (vs. 140) degrees. This was also accompanied by limited rotation in the end flexion position. Experience has taught me that a safe return to a sport where deep flexion is expected cannot be guaranteed until these parameters have returned to normal.
The above cases have been chosen to point out a few of the practical advantages of using some form of artistic documentation of surgical pathology and treatment. The importance of incorporating art into medical practice can be found in one or more of the following paragraphs.
There is clear educational value in providing clear orientation of pathology and treatment at surgery. Sketches or illustrations provide a basis for the rehabilitation plan recommended and demonstrates caregivers are concerned enough about maximizing the outcome of that treatment plan to make sure all pertinent features of the patient's problem at the time of surgery were understood and recorded.
Then too, illustrations provide for excellent resident training. Anyone viewing these sketches gains an immediate and accurate perspective on the post-surgical management in the office setting. Errors can creep into a patient record as the chart becomes voluminous and the original problems become remote (or obscure to the point they are misrepresented, in long or complicated cases). With electronic medical record systems, all images are immediately accessible for conference presentations as well as for immediate patient care.
Surgical illustrations provide rapid and reliable orientation for health care providers when patients call with unexpected complaints or unusual requests. A quick reference to the diagram shows what was actually done.
In complicated cases, in particular, there is value in understanding and orienting to important features brought out by surgical sketches that might affect outcome. I often provide a copy of the surgical illustration to my patients to take to their physical therapy provider so requests for important deviations from standard therapeutic protocols will be clearly understood. Illustrations can also remind examiners about the details of surgery which might not have held any importance unless postoperative problems unfold. A common example is the existence of chondromalacia. A sketch often provides the only documentation of the existence of other pathologies which could explain a patient's new complaint once the more-major symptoms (which led to the surgery) have been addressed.
Not everyone will have the time for, or be comfortable with, creating a sketch from scratch. However, there are alternative methods of visual documentation available. There are a number of companies and organizations who provide templates for medical documentation. These always contain a drawing of the involved body part (e.g., knee, ankle, shoulder, elbow, hand, spine). While the sketches can be created on plain paper, it may be best to consider permanent storage as part of an electric medical record system via electronic scanning.
The University of Iowa Hospitals and Clinics is currently using Epic as its electronic medical record system. This program has the capacity to accept scanned photographs and graphic illustrations (in color) for inclusion in the patient's electronic medical record. Particularly in more complicated cases, multiple sketches can be included in the records so health care practitioners may comprehend all of the details involved. Documented below are two sketches from a 350-pound male with a dislocated knee causing peroneal nerve disruption and partial popliteal artery compromise. A second sketch was required to clarify the details of procedures performed for this dislocated and vascularly compromised knee.
Electronic sketch pads are available for both PC and Mac systems. While Photoshop has the capacity to create a sketch, it is not only complicated to use, it also does not generate the smooth lines available with the Painter program sketches.
I recently began taking a portable computer with a sketch pad into the operating room. The software program I find most helpful has been Corel Draw: Painter Essentials 4, though there are other programs that could be used. The Corel program allows me to accurately create images that are as good as if they were sketched in pencil. In addition, because handwritten notes can be impossible to read, the typed text in Corel Draw is much more attractive, can contain more detail and is more efficient. I have included a selected sketch from one of my early attempts, a crude example of what this method offers.
There is one last illustration method worth mentioning that I am currently trying. This particular electronic medium has an endless library of templates that users can accumulate. These can help document almost every situation providers encounter in their personal practice experience.
The following drawing is of a tibial tubercle transfer procedure with MPFL reconstruction. The transfer was required to eliminate recurrent patellar dislocations and the “J sign,” which was assessed intra-operatively (by femoral nerve stimulation) to be 25 mm. The pertinent details of the case are typed into the text bar to the left. Enlargement of the image is easily achieved to read the printed details of the case.