OT notes · Orthopaedics

Arthrodesis (small joints of hand/foot; hip, knee, shoulder, elbow, ankle)

Usual anaesthesia
Regional (spinal or peripheral nerve block) and/or general for large joints; brachial plexus block for hand and wrist
Position
Depends on joint: supine with a bump under the hip for ankle; supine arm on hand table for hand and wrist; lateral for hip
Setting
elective

Operative note template for arthrodesis of a joint (finger, wrist, ankle, knee, hip, shoulder or elbow), with a filled example for an open transfibular ankle arthrodesis with cannulated screws for post-traumatic arthritis.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • non-union, may need revision and bone graft
  • fusion in a poor position (malunion)
  • permanent loss of movement of the joint
  • wound infection and wound breakdown
  • injury to nearby cutaneous nerves (numbness)
  • blood vessel injury
  • deep vein thrombosis
  • arthritis of neighbouring joints in later years
  • prominent screws or plate that may need removal
  • donor-site pain if bone graft is taken

Pre-operative details for this operation

  1. Joint and sidee.g. left ankle (tibiotalar), right index PIP
  2. Diagnosis and indicationPost-traumatic arthritisOsteoarthritisRheumatoid / inflammatory arthritisPost-infective arthritisParalytic / unstable jointFailed arthroplastyCharcot jointand conservative treatment already tried
  3. Deformity before surgerycoronal and sagittal deformity in degrees, fixed or correctable
  4. Neighbouring jointsstate of hindfoot / knee / hip for ankle; wrist and other fingers for hand
  5. Skin and old scars over the approach
  6. Vascular statuspulses; Doppler if pulses weak or long-standing diabetes
  7. Infection work-up if post-infective or post-open-fractureESR, CRP, TLC
  8. Risk factors for non-unionsmoking (stopped?), diabetes with HbA1c, vitamin D, anti-TNF drugs stopped
  9. Imagingweight-bearing X-rays; CT if bone loss or cysts
  10. Implants and graft planscrews / plate / K-wires / nail / external fixator available; graft source

Anaesthesia and position

  1. AnaesthesiaSpinalSpinal with popliteal / femoral blockGeneral with nerve blockBrachial plexus block
  2. PositionSupine with bump under ipsilateral hipSupine, arm on hand tableLateralBeach chair
  3. Tourniquetthigh / calf / arm, pressure in mmHg, time up and down
  4. C-armUsedNot used

Operative findings

  1. Articular surfacecartilage loss, eburnation, cysts, osteophytes, bone loss
  2. Bone qualityGoodOsteopenicSclerotic / avascular areas
  3. Signs of infectionNonePresent: sample sent
  4. Neighbouring joint seene.g. subtalar joint osteophytes

Procedure (steps)

  1. ApproachTransfibular (lateral)AnteriorMini-incision (two 1.5 cm arthrotomies)ArthroscopicDorsal (hand / wrist)Otherincision length; nerves protected (superficial peroneal, dorsal intermediate cutaneous, sural)
  2. Fibular osteotomy (transfibular only)level above plafond, segment removed, medial half excised, lateral half kept on its soft tissue
  3. Osteophytes removed
  4. Joint preparationcartilage removed with curette / osteotome / saw; in-situ contour or flat cuts; subchondral bone drilled or feathered; bleeding cancellous bone reached
  5. Guttersmedial gutter prepared; lateral gutter prepared or not
  6. Additional procedurese.g. tendo-Achilles triple hemisection for equinus; wedge for deformity
  7. Position of fusionwrite the actual angles. Ankle: neutral flexion, about 5 degrees valgus, about 5 degrees external rotation, talus slightly back. Knee: 0 to 15 flexion, 5 to 8 valgus, 10 external rotation. Hip: 20 to 30 flexion, 0 to 5 adduction, 0 to 15 external rotation. Shoulder: 10 to 20 abduction, 10 to 20 flexion, 35 to 45 internal rotation (position most authors prefer). Elbow: 90 to 100 flexion (one side). Finger MCP 20 to 30, PIP 25 (index) to 40 (little), DIP 0 to 20 flexion
  8. Provisional fixation and C-arm checkK-wires / guide wires; AP and lateral
  9. Bone graftNoneLocal (resected fibula / osteophytes)Iliac crestProximal tibiaAllograft / substitute
  10. Definitive fixationnumber, diameter, length and type (partially / fully threaded) of screws, order of insertion; plate type and screw count; K-wires with tension band; headless screw; nail; external fixator
  11. Final C-arm imagesposition of fusion and implant length confirmed; images saved
  12. Irrigation, tourniquet release and haemostasis

Closure, drains and dressing

  1. Capsule / periosteum / extensor mechanismclosed over the implants where possible
  2. Subcutaneous tissuesuture and size
  3. Skinsuture and size; no tension
  4. DrainNoneSuction drain
  5. Splint / casttype and position, e.g. well-padded below-knee slab with foot in neutral

Specimens and implants

  1. Implantseach screw / plate / wire: type, diameter, length, make, batch / lot number; stickers pasted
  2. Bone graft usedsource and amount
  3. Tissue for culture / HPESentNot sentif infection or inflammatory arthritis suspected

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Limb elevationon pillows above heart level
  2. Neurovascular checktoe or finger colour, capillary refill, sensation, movement; tight splint to be loosened
  3. Weight bearingnon-weight bearing on the operated limb; walker or crutches
  4. Analgesiadrug, dose, frequency
  5. Thromboprophylaxisas per unit protocol for lower-limb surgery
  6. Check X-rayAP and lateral of the fused joint
  7. Wound reviewsplint and sutures off at 10 to 14 days; non-weight-bearing cast applied
  8. Cast carereturn if the cast becomes loose
  9. Follow-upX-rays for union; ankle: cast 4 to 8 more weeks, then walking boot 4 weeks; rocker-sole shoe if needed
  10. Stop smoking; blood sugar controlboth slow union

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. R.M., 46 years, farmer, painful stiff left ankle 4 years after a bimalleolar fracture treated in plaster. Walking limited to 200 m despite analgesics, ankle brace and footwear change. X-rays show loss of the tibiotalar joint space with 8 degrees of varus tilt. Subtalar joint normal.

Case details

Date: 22/07/2026. Elective. OT 1.

In OT 09:05. Spinal given 09:15. Tourniquet up 09:40. Tourniquet down 11:15. Out of OT 11:45.

Surgeon: Dr C. (Consultant, Orthopaedics). Assistant: Dr A. (3rd-year resident), did the exposure, fibular osteotomy and closure. Second assistant: Dr B.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Diagnosis: post-traumatic arthritis left ankle with 8 degrees varus. Failed conservative treatment for 2 years.

Dorsalis pedis and posterior tibial pulses felt. Skin healthy, no previous incision. Non-smoker. FBS 96 mg/dl. ESR 12 mm/h, CRP normal.

Weight-bearing AP, mortise and lateral X-rays and CT reviewed. No bone loss.

Implants checked: 6.5 mm cannulated cancellous screws and 3.5 mm cortical screws available.

Consent: general, procedure-specific and anaesthesia consent taken in Marathi. Risks explained: non-union, malunion, infection, nerve injury, DVT, stiffness of the ankle for life, later arthritis of foot joints, rocker-sole shoe.

WHO checklist sign in and time out done. Left side marked. Inj cefazolin 2 g IV at 09:25.

Anaesthesia and position

Spinal anaesthesia. Supine on radiolucent table with a sandbag under the left hip. Thigh tourniquet at 300 mmHg after exsanguination. Parts painted with povidone-iodine and chlorhexidine and draped. C-arm from the opposite side.

Findings

Full-thickness cartilage loss over the lateral two-thirds of the talar dome and plafond. Large anterior tibial and talar osteophytes. Medial gutter narrowed. Bone quality good. No sign of infection.

Procedure

Lateral longitudinal incision over the distal fibula, curved 2 cm beyond the tip along the peroneal tendons. Superficial peroneal nerve branch identified and protected.

Anterior osteophytes removed with osteotome and mallet.

Fibula cut with a sagittal saw 6 cm above the plafond, 1 cm segment removed. Syndesmosis released anteriorly, posterior ligaments kept. Medial half of the distal fibula excised, lateral half kept on its periosteum and reflected back.

Joint opened with a lamina spreader. Cartilage removed from plafond and talar dome with curettes and osteotomes, keeping the normal contour. Separate small anteromedial incision to clear the medial gutter. Subchondral bone drilled with a drill bit under saline cooling. Bleeding cancellous bone on both sides.

Ankle held in neutral flexion, 5 degrees valgus, 5 degrees external rotation, talus slightly back under the tibia. Two guide wires passed. Position checked on C-arm AP and lateral.

Excised medial fibula morselised and packed into the joint as graft.

Two partially threaded 6.5 mm cannulated cancellous screws (75 mm posterolateral tibia to talar neck, 70 mm posteromedial tibia to talar body) for compression, then one fully threaded 6.5 mm screw (65 mm) from the lateral process of the talus into the tibia.

Lateral tibia and talus freshened. Fibula laid back as an onlay and fixed to tibia and talus with two 3.5 mm cortical lag screws (40 mm and 36 mm). Subtalar joint not impinged.

Final C-arm images saved: good compression, screws not in the subtalar joint. Wound washed with normal saline. Tourniquet released at 11:15 (95 min). Haemostasis secured.

Closure

Subcutaneous tissue with polyglactin 910 (Vicryl) 2-0. Skin with interrupted nylon (Ethilon) 3-0. No drain.

Sterile dressing. Well-padded below-knee posterior slab with the foot in neutral.

Specimens and implants

Implants: 6.5 mm cannulated cancellous screws x 3 (75, 70, 65 mm); 3.5 mm cortical screws x 2 (40, 36 mm). Make, lot numbers and stickers pasted in the implant record.

Graft: local, from excised medial half of the fibula. No specimen sent.

End of procedure

Blood loss about 150 ml. No transfusion. Mop, needle and instrument count correct.

No intra-operative complications.

Shifted to ward, stable. Pulse 78/min, BP 128/80 mmHg. Toes warm and pink.

Post-op orders

Left leg elevated on two pillows. Check toe colour, capillary refill, sensation and movement hourly for 6 hours.

Strict non-weight bearing on the left leg; walker from POD 1 with physiotherapist.

Analgesia and thromboprophylaxis as per unit protocol.

Check X-ray left ankle AP and lateral on POD 1.

Review at 2 weeks for slab and suture removal and below-knee non-weight-bearing cast.

Signature

Dr A., JR-3, Orthopaedics, for Dr C. Reg. no. ________. 22/07/2026, 12:00.

Must document for this operation

  • The position of fusion in degrees in each plane. A fused joint cannot be moved later, and malposition (for example ankle extension or varus) is a common reason for revision.
  • How the joint surfaces were prepared and whether the gutters were prepared. If the fusion does not unite, the revising surgeon needs to know what was done.
  • Each implant with diameter, length, type, make and lot number. Needed for implant traceability and for planning removal or revision.
  • Bone graft source and amount. Explains donor-site symptoms and helps plan any revision graft.
  • Nerves seen and protected in the approach. Cutaneous nerve numbness after ankle fusion is common, and the note shows care was taken.
  • Any added procedure, such as heel-cord lengthening. An added procedure needs its reason written and must be covered by the consent.
  • Tourniquet pressure and time. Required for audit and relevant if there is later nerve palsy or wound trouble.

Common mistakes in these notes

  • Writing 'joint fused in functional position' without the angles.
  • Not recording the screw sizes and lengths, or the implant stickers.
  • Leaving out whether the fibula was kept as an onlay graft or removed.
  • Not documenting the pre-operative pulses and skin condition.
  • Not writing the weight-bearing instruction clearly (non-weight bearing, which limb, for how long).

Indian practice and paperwork

  • Record the batch and serial number of every screw and plate in the case sheet. NABH also asks for it in the implant master logbook and the discharge summary. (NABH Accreditation Standards for Hospitals, 5th ed. (2020), MOM.10(d))
  • Consent must cover the procedure, risks, benefits, alternatives (here arthroplasty or continued bracing) and who will operate, in a language the patient understands. (NABH 5th ed. (2020), PRE.4(c))
  • Campbell notes that in developing countries with limited resources, hip fusion is still a main option for painful hip arthritis, so residents may still see it done. (Campbell's Operative Orthopaedics 15e, Ch 6, p. 349)

Sources

  • Azar FM, Sawyer JR, et al., eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier, Ch 12, Ankle arthrodesis (indications, mini-incision, transfibular and anterior techniques); Ch 6, Arthrodesis of the hip; Ch 9, Arthrodesis of the knee; Ch 14, Shoulder arthrodesis; Ch 15, Elbow arthrodesis; Ch 78, Finger joint arthrodesis, pp. 561-570; 349-353; 472-480; 624-627; 663; 3467-3470.
  • Azar FM, Beaty JH, eds. Campbell's Core Orthopaedic Procedures. 2nd ed. Elsevier; 2024, Technique 50, Ankle arthrodesis: mini-incision technique (Bettin CC), pp. 235-237.
  • Saghieh S, Weinstein SL, Hoballah JJ, eds. Operative Dictations in Orthopedic Surgery. Springer; 2013, Ch 57, Ankle fusion (Huang MJ); Ch 88, Wrist fusion (Shamseddeen A), pp. 209-210; 321-322.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision, redose at 4 h; cefazolin recommended when internal fixation devices are implanted. academic.oup.com/ajhp/article/70/3/195/5112717
  • Campbell's Operative Orthopaedics 15e, Ch 2, Tourniquets, pp. 137-138: 175-305 mmHg satisfactory for the lower limb; tourniquet time 2 hours or less in healthy adults under 50.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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