Knee Arthroscopy Operative Report (Meniscectomy/Chondroplasty)

Patient: [Full name]; [MRN / DOB]

Date of Surgery: [Date]

Surgeon: [Surgeon's full name, credentials]

Assistant(s): [Assistant name(s) / none]

Facility/OR: [Facility name and OR number]

Laterality: [Right / Left] (Must be explicitly stated; do not infer.)

Anesthesia: [General / Regional / MAC]

Preoperative Diagnosis

• [Diagnosis with laterality and anatomic specificity] (Use separate bullets for multiple diagnoses.)

Postoperative Diagnosis

• [Final intraoperative diagnosis with laterality and anatomic specificity] (If a suspected pathology was not present, explicitly state its absence.)

Procedure(s) Performed

• [Diagnostic knee arthroscopy, laterality]
• [Partial meniscectomy - medial / lateral / both, laterality]
• [Chondroplasty - compartment/location, laterality]
• [Loose body removal, laterality]
• [Synovectomy - focal / diffuse, laterality, location]
• [Plica excision - medial / lateral / suprapatellar, laterality]

(Include only procedures actually performed. Each procedure must include laterality.)

Indications

[Presenting symptoms and duration] [Failed conservative measures] [Pertinent examination findings] [Pertinent imaging findings supporting surgery] (3–5 sentences; include details only if explicitly documented.)

Consent and Time-Out

[Confirmation of informed consent obtained; site marked] [Time-out performed per protocol confirming patient, procedure, and laterality].

Perioperative Details

• Position: [Supine with leg holder / position described]
• Tourniquet: [Not used / Used at location, pressure in mmHg, total time in minutes]
• Antibiotic prophylaxis: [Administered / Not administered]
• EBL: [Estimated blood loss in mL]
• Specimens: [None / specimen description and source]
• Implants: [None / implant details]
• Complications: [None / complication description and management]

Findings

Cartilage grading system used: [Outerbridge (0–IV) / ICRS (0–4)] (State chosen system and use consistently throughout.)

(Only document structures visualized. If a region was not examined, state "not examined." Do not label as normal unless explicitly visualized and normal.)

Suprapatellar Pouch and Patellofemoral Joint

• Suprapatellar pouch: [Loose bodies / synovitis / adhesions / normal / not examined]
• Patella articular cartilage: [Medial facet grade] [Lateral facet grade] [Odd facet grade] (Include focal lesion description and size if applicable.)
• Trochlear groove: [Cartilage grade, lesion type and size if present]

Medial Compartment

• Medial Meniscus: [Intact / Tear present] (If torn: location [anterior horn / body / posterior horn / root], pattern [longitudinal / horizontal / radial / flap / complex], depth [partial / complete], tissue quality [degenerative / nondegenerative], stability. If meniscectomy performed, note percent excised and residual rim stability.)
• Medial Femoral Condyle: [Cartilage grade] [Lesion location: weight-bearing / non-weight-bearing; anterior / central / posterior] [Lesion type: fissure / flap / delamination / defect] [Size if measurable] (If chondroplasty performed, note technique and whether stable margins achieved.)
• Medial Tibial Plateau: [Cartilage grade, lesion description if present]

Intercondylar Notch

• ACL: [Intact / Partial tear / Complete tear]
• PCL: [Intact / Partial tear / Complete tear]
• Other: [Loose bodies / synovitis / notch osteophytes / none]

Lateral Compartment

• Lateral Meniscus: [Intact / Tear present] (If torn: location, pattern, depth, tissue quality, stability. If meniscectomy performed, note percent excised and residual rim stability.)
• Lateral Femoral Condyle: [Cartilage grade, lesion description and size if present]
• Lateral Tibial Plateau: [Cartilage grade, lesion description if present]

Medial and Lateral Gutters

[Loose bodies / synovitis / osteophytes / plica / normal / not examined] (Describe bilaterally as visualized.)

Posterior Compartments

[Findings via trans-notch view] (If not examined, state: "Posterior compartments not examined." Do not leave blank or imply normal if not visualized.)

Loose Bodies Summary

[Number, size, and location of loose bodies; confirmation of removal] (If none: "No loose bodies identified.")

Procedure in Detail

Approach: [Portal placement: anterolateral viewing, anteromedial working; accessory portals if used] [Scope: 30-degree / other].

Meniscectomy technique (if performed): [Instruments used] [Technique: resection of unstable tissue with preservation of stable rim] [Percent removed] [Confirmation of stable residual rim with probe].

Chondroplasty technique (if performed): [Method: mechanical shaver / curette] [Debridement to stable margins] [Subchondral bone exposed: yes / no] [Irrigation and debris removal].

Loose body removal (if performed): [Retrieval method] [Confirmation of complete removal].

Closure: [Portal closure method] [Local anesthetic injection if administered] [Dressing applied].

Disposition

[Patient transferred to PACU in stable condition] [Immediate concerns if any].

Postoperative Plan

• Weight-bearing: [WBAT / Partial / Restricted] for [duration]
• ROM/Brace: [As tolerated / restrictions specified; brace if applicable]
• Physical therapy: [Start timing; focus areas]
• DVT prophylaxis: [Per protocol / specific agent and duration]
• Wound care: [Dressing removal timing; showering instructions]
• Follow-up: [Timeframe]
• Return precautions: [Fever, increasing redness/drainage, calf pain or shortness of breath, uncontrolled pain]

Signature

[Surgeon signature, date, and time]

(For any required field where information is not provided in dictation, use [NOT DOCUMENTED] rather than omitting or inferring. Do not infer laterality. Ensure cartilage findings specify the grading system used.)