OT notes · Orthopaedics

Soft-tissue release for contracture (hip / knee / elbow)

Usual anaesthesia
General anaesthesia for hip and knee releases in children; regional block (infraclavicular, often with catheter) with or without general for elbow release
Position
Hip: lateral. Knee: prone or supine. Elbow: supine with arm on hand table and a folded towel under the scapula
Setting
elective

Operative note template for soft-tissue release of a fixed contracture of the hip, knee or elbow, with a filled example for an Ober-Yount release of a post-polio flexion-abduction-external rotation contracture of the hip.

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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

  • incomplete correction or recurrence of the contracture
  • nerve stretch or injury on correcting the deformity (sciatic at hip and knee, ulnar at elbow)
  • weakness of the muscles released or lengthened
  • wound infection and haematoma
  • stiffness after cast or brace
  • need for bone surgery (osteotomy) later if soft-tissue release is not enough
  • long-term brace and physiotherapy
  • heterotopic ossification after elbow release

Pre-operative details for this operation

  1. Joint, side and deformitye.g. left hip: flexion 30 degrees, abduction 25 degrees, external rotation 20 degrees; measured by goniometer (Thomas test for hip flexion)
  2. CausePost-polio residual paralysisPost-traumaticPost-burnCerebral palsy / spasticArthrofibrosisOther
  3. Muscle chartingpower (MRC grade) of muscles around the joint; which are paralysed
  4. Related deformitiespelvic obliquity, limb-length difference, genu valgum, tibial external torsion, lumbar lordosis / scoliosis
  5. Nerve statussciatic / peroneal before hip or knee release; ulnar nerve before elbow release
  6. ImagingX-ray of the joint and pelvis; heterotopic bone, joint surface changes
  7. Non-operative treatment triedstretching, serial casts, splints, and duration
  8. Post-op plan agreedspica / long leg cast / brace / CPM, physiotherapy availability

Anaesthesia and position

  1. AnaesthesiaGeneralGeneral with regional blockInfraclavicular block with catheter
  2. PositionLateralProneSupine, arm on hand table
  3. TourniquetNot usedArm / thigh tourniquetpressure and time
  4. Deformity measured under anaesthesiaangles before release

Operative findings

  1. Structures found tighthip: TFL / iliotibial band, sartorius, rectus, iliopsoas, glutei, capsule. Knee: ITB, hamstrings, posterior capsule. Elbow: anterior / posterior capsule, osteophytes, heterotopic bone
  2. Muscle qualityfibrotic / fatty / normal
  3. Nerve position and adhesione.g. ulnar nerve scarred in cubital tunnel
  4. Correction achieved after each stepangles

Procedure (steps)

  1. Incisionhip: transverse below and medial to ASIS extending above greater trochanter (Ober), or along anterior iliac crest (Campbell); Yount: lateral thigh just above femoral condyle; elbow: lateral (Kocher) or medial / posterior
  2. Nerves identified and protectedsciatic nerve at the hip; at the elbow ulnar, median, radial and medial antebrachial cutaneous nerves
  3. Structures released, in ordername each: divided, lengthened, detached or excised; length of any segment excised
  4. Correction checked after each releasestop when correction is full; divide further structures only if still tight
  5. CapsulotomyNot neededAnteriorPosteriorBothhip, Ober-Yount: capsule opened from anterior to posterior parallel with the labrum, after retracting the sciatic nerve (routine step). Hip, Campbell crest release: capsule divided obliquely proximal to distal only if the hip still cannot be hyperextended. Knee: posterior capsulotomy with hamstring release. Elbow: anterior and / or posterior capsule excised
  6. Bony workNoneResection of redundant iliumOlecranon / coronoid osteophytes excisedHeterotopic bone excised
  7. Nerve procedureNoneUlnar nerve released in situUlnar nerve transposed anteriorly
  8. Final range under anaesthesiaangles in each plane; distal pulses after correction
  9. Haemostasistourniquet released before closure if used

Closure, drains and dressing

  1. Muscle reattachmente.g. flexor-pronator origin with braided non-absorbable 1-0 or 0
  2. DrainSuction drainNone
  3. Skinsuture and size
  4. ImmobilisationHip spica in extension, 10 degrees abduction, internal rotationLong leg cast / splint in extensionTraction pinsElbow splint / CPMwrite the position

Specimens and implants

  1. SpecimenNoneHeterotopic bone / capsule for HPE
  2. Implantstraction pins or hinged external fixator: type, size, batch; or 'none'

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. Neurovascular checkdistal pulses, foot or hand movement and sensation; sciatic / peroneal or ulnar nerve function
  2. Cast / spica carecheck edges, pressure areas, and that the position is held
  3. Drainrecord output; remove when minimal
  4. Analgesiadrug, dose, frequency; regional catheter if placed
  5. Antibioticsstop within 24 hours, or while drain is in if unit policy
  6. Cast removal and bracehip release: cast off at 2 weeks, long leg brace with pelvic band in the corrected position
  7. Physiotherapystretching to hold correction; elbow: therapy and CPM from day of surgery, daily for 3 weeks
  8. Night splintto prevent recurrence
  9. Follow-upmeasure angles at each visit and compare with pre-op

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: Master A.S., 11 years, 32 kg, post-polio residual paralysis of the left lower limb since age 2. Walks with hand-to-knee gait. Left hip fixed flexion 35 degrees, abduction 25 degrees, external rotation 20 degrees. Pelvic obliquity, iliac crest low on the left. Gluteus maximus grade 2, quadriceps grade 2.

Case details

Date: 10/09/2026. Elective. OT 4.

In OT 09:00. GA induced 09:10. Incision 09:40. Spica completed 11:20.

Surgeon: Dr C. (Consultant, Orthopaedics). Assistant: Dr A. (2nd-year resident), did the Yount fasciotomy and closure. Second assistant: Dr B.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Diagnosis: post-polio flexion-abduction-external rotation contracture of the left hip with contracted iliotibial band, not corrected by 6 months of stretching.

Left sciatic and peroneal nerve function intact. Hb 11.8 g/dl. X-ray pelvis: hips located, pelvic obliquity.

Consent: taken from father in Hindi, child assented. Explained: recurrence, nerve stretch, weakness, spica for 2 weeks, brace and physiotherapy for a long time, possible bone surgery later.

WHO checklist sign in and time out done. Left side marked. Inj cefazolin 1 g IV (about 30 mg/kg) at 09:20.

Anaesthesia and position

General anaesthesia. Right lateral position. Parts painted with povidone-iodine and draped, whole left limb free. No tourniquet.

Under GA: fixed flexion 35 degrees, abduction 25 degrees, external rotation 20 degrees.

Findings

Tight tensor fasciae latae and iliotibial band, tight sartorius and rectus origins, tight iliopsoas tendon. Muscles pale and partly fatty.

At the knee, iliotibial band and lateral intermuscular septum tight.

Procedure

Transverse incision below and medial to the anterior superior iliac spine, carried laterally above the greater trochanter.

Iliopsoas tendon divided distally and 1 cm excised.

Sartorius detached from the ASIS, rectus femoris detached from the AIIS, tensor fasciae latae divided from its anterior border back to its posterior border.

Hip re-checked: flexion deformity 10 degrees, abduction 10 degrees, external rotation 10 degrees. Gluteus medius, minimus and short external rotators detached from the greater trochanter. Sciatic nerve identified, retracted posteriorly and protected. Hip capsule opened from anterior to posterior, parallel with the acetabular labrum.

Yount fasciotomy: lateral longitudinal incision just above the lateral femoral condyle. Iliotibial band and fascia lata divided from the biceps tendon to the midline of the thigh 2.5 cm above the patella. A 6 cm segment of band and lateral intermuscular septum excised.

All tight bands checked by palpation and found divided.

Final range: full hip extension, adduction to neutral, internal rotation 10 degrees. Dorsalis pedis pulse present after correction. Haemostasis secured.

Closure

Hip wound closed in layers over a suction drain. Knee wound closed in layers, no drain.

Hip spica on the left with hip in full extension, 10 degrees abduction and slight internal rotation.

End of procedure

Blood loss about 200 ml. No transfusion. Mop, needle and instrument count correct.

No intra-operative complications. No specimen. No implant.

Shifted to ward. Pulse 96/min, BP 104/66 mmHg. Toes pink and moving.

Post-op orders

Check left foot colour, pulse, toe movement and sensation hourly for 6 hours, then 4-hourly. Report foot drop at once.

Spica care: check edges and pressure areas each shift.

Drain output to be charted; remove when minimal.

Analgesia as per paediatric anaesthesia chart.

Spica removal at 2 weeks and fitting of long leg brace with pelvic band in the corrected position. Physiotherapy referral.

Signature

Dr A., JR-2, Orthopaedics, for Dr C. Reg. no. ________. 10/09/2026, 11:40.

Must document for this operation

  • Deformity angles before surgery, under anaesthesia and after release. The gain in angle is the result of the operation and the baseline for judging recurrence.
  • Each structure released, with how it was released (divided, detached, excised, lengthened). A surgeon doing a repeat release or a tendon transfer later needs to know what is left.
  • Whether the capsule was opened. Capsulotomy changes joint stability and later surgical planning.
  • Nerve function before and after correction. Sudden correction can stretch the sciatic, peroneal or ulnar nerve, and the note fixes when a deficit started.
  • Position of the cast or brace. The correction is held only if the immobilisation position is right.
  • Muscle power of the paralysed limb. Weak muscles explain residual limp and guide later tendon transfers.

Common mistakes in these notes

  • Writing 'contracture released' without naming the structures cut.
  • Giving only the final angle, not the pre-operative angle.
  • Not recording the distal pulse and nerve check after correction.
  • Leaving out the spica or brace position.
  • For elbow release, not stating whether the ulnar nerve was released or transposed.

Indian practice and paperwork

  • For a minor, consent is taken from the parent or guardian. It must explain the procedure, risks, benefits, alternatives and who will operate, in a language they understand. (NABH 5th ed. (2020), PRE.4(c))
  • NABH expects the operative note to be written before the patient leaves recovery, and post-op care to follow a written plan. (NABH 5th ed. (2020), COP.14(e) and (f))

Sources

  • Azar FM, Sawyer JR, et al., eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier, Ch 36, Paralytic disorders (poliomyelitis): flexion contracture of the knee; flexion and abduction contractures of the hip, eTechniques 36.18 (Ober; Yount) and 36.19 (Campbell), pp. 1278.e17-1278.e24.
  • Chapman MW, James MA, eds. Chapman's Comprehensive Orthopaedic Surgery. 4th ed. Jaypee Brothers; 2019, Ch 113, Elbow stiffness (open lateral column and medial over-the-top releases, positioning, post-op care), e-book PDF pp. 2028-2039.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin paediatric dose 30 mg/kg; adult 2 g; within 60 min before incision. academic.oup.com/ajhp/article/70/3/195/5112717
  • Chapman's Comprehensive Orthopaedic Surgery 4e, Ch 113 (pdf 2031): weight-based cefazolin before tourniquet and incision; stop within 24 h if no drain.

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.

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