OT notes · Orthopaedics

Arthrotomy and joint lavage (knee / hip / ankle / shoulder / elbow)

Usual anaesthesia
Spinal for lower-limb joints; general for shoulder and elbow, and in children
Position
Supine for knee, anterior hip, ankle and elbow (arm on side table); beach-chair or supine with a bump for shoulder; lateral for posterior hip drainage
Setting
emergency

Operative note template for open arthrotomy, drainage and lavage of a septic large joint, with a filled example for an anteromedial arthrotomy of an adult septic knee.

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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

  • infection may persist and need repeat washout
  • damage to joint cartilage, later arthritis
  • joint stiffness
  • nerve or vessel injury (depends on joint: common peroneal, sciatic, ulnar, radial, axillary)
  • avascular necrosis of the femoral head (hip)
  • wound breakdown or sinus
  • pathological dislocation (hip in children)
  • spread of infection, sepsis

Pre-operative details for this operation

  1. Joint and sideKneeHipAnkleShoulderElbowWristOther
  2. Duration of symptoms and clinical statedays of pain and swelling, fever, sepsis signs, range of motion
  3. Aspiration resultdate, appearance, cell count, Gram stain, crystals, culture sent
  4. Blood testsESR, CRP, total count, blood culture sent, blood sugar
  5. ImagingX-ray (bone changes), ultrasound / MRI (effusion, abscess, osteomyelitis)
  6. AntibioticsNot yet started: withheld till cultures takenStarted after aspiration (drug, dose, time)On antibiotics before admission (cultures may be negative)
  7. Reason for open rather than arthroscopic drainagedeep joint (hip), thick pus or loculations, failed aspiration, no arthroscopy set

Anaesthesia and position

  1. AnaesthesiaSpinalGeneralRegional block
  2. Positionsupine / lateral / beach-chair; bumps and supports
  3. TourniquetNot usedUsed after elevation, no Esmarchpressure, time up and down

Operative findings

  1. Joint fluidvolume, colour and consistency (turbid / frank pus / blood-stained)
  2. Synoviuminflamed / thickened / fibrin deposits / loculations
  3. Articular cartilageintact / softened / eroded; which surfaces
  4. Stage (Gächter)IIIIIIIVI cloudy fluid, reddened synovium; II pus, fibrin; III thick synovium, compartments; IV pannus into cartilage, bone changes on X-ray
  5. Boneany subchondral erosion or communication with metaphyseal osteomyelitis

Procedure (steps)

  1. ApproachKnee: anteromedial parapatellarKnee: posterolateral / posteromedial (Henderson) addedHip: anteriorHip: lateralHip: posterior (Ober)Ankle: anterolateral / anteromedial / posterolateral / posteromedialShoulder: anterior (deltoid split, rotator interval)Shoulder: posteriorElbow: lateral / medial / posteriorlength of incision
  2. Structures protectede.g. saphenous branches (knee), lateral femoral cutaneous nerve (anterior hip), sciatic nerve (posterior hip), ulnar or radial nerve (elbow), sural nerve (posterolateral ankle)
  3. Capsule openedwhere and how long
  4. Fluid sent before washoutGram stain, aerobic culture and sensitivity; AFB / fungal culture if suspected
  5. Pus evacuated, loculations and adhesions broken
  6. Debridementfibrin, necrotic tissue; partial synovectomy if done; synovial tissue sent for culture and HPE
  7. Irrigationfluid and volume in litres, until the return is clear
  8. Additional procedureNoneDrilling of metaphysis (child, shoulder / hip)Posterior counter-incision for posterior compartment

Closure, drains and dressing

  1. SynoviumLeft open
  2. CapsuleClosed loosely over drain with absorbable monofilamentLeft open (hip)
  3. Draintype and size, where it comes out
  4. Skinclosed loosely over drain; suture used
  5. Splintjoint and position (knee in functional position; ankle at 90 degrees; elbow at 90 degrees, forearm neutral; shoulder in sling; child's hip in abduction)

Specimens and implants

  1. Joint fluid / pusGram stain, culture and sensitivity, AFB, fungal; number of containers
  2. Synovial tissuefor culture and for HPE (TB, inflammatory arthritis)
  3. ImplantsNone

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. IV antibioticsempirical drug, dose, frequency; change when culture report comes; ID or microbiology consult
  2. Temperature, pulse, sepsis watchfrequency
  3. Drainrecord output; usual removal at 24-48 h after knee drainage
  4. Splintposition; knee splint kept about one week except during exercises
  5. Exercisesknee: straight-leg raising and quadriceps setting from day 0; active motion when comfortable, usually from 24 h
  6. Distal neurovascular status
  7. Repeat CRP / countsday and frequency; plan repeat washout if no improvement
  8. Follow up culture and HPE reportsnote the date due
  9. Weight bearingas allowed; graduated after the wound heals for ankle

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. V.M., 34 years, no diabetes or other illness, pain and swelling of the left knee for 3 days with fever. Aspiration: 40 ml turbid fluid, Gram-positive cocci in clusters. No arthroscopy set available on the emergency list.

Case details

Date: 03/08/2026. Emergency list. OT 1.

In OT 21:40. Spinal 21:48. Skin incision 22:02. Closure 22:50.

Surgeon: Dr A. (2nd-year resident, Orthopaedics). Assistant: Dr B. Consultant: Dr C., present.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Acute septic arthritis left knee, 3 days. Temperature 38.9 C, knee held at 30 degrees flexion, movement painful.

Aspirate (casualty, 17:30): 40 ml turbid fluid; Gram-positive cocci in clusters; sent for cell count, crystals and culture.

CRP 142 mg/L, ESR 68 mm/h, TLC 15,800/cumm. Blood culture sent 17:45. RBS 104 mg/dl. X-ray left knee: effusion, no bone change.

Inj cefazolin 2 g IV 8-hourly started at 18:10 after aspirate and blood culture were taken (no MRSA risk factors).

Consent in Hindi, including repeat washout. Left knee marked. WHO checklist done.

Anaesthesia and position

Spinal anaesthesia. Supine. Tourniquet on left thigh; limb elevated, no Esmarch; inflated at 21:58 (pressure recorded on anaesthesia chart).

Painted with povidone-iodine and draped.

Procedure

Medial parapatellar incision 9 cm. Capsule and synovium incised in line.

Findings: about 60 ml thick yellow pus. Synovium red and swollen with fibrin deposits and a few loculations (Gächter II). Articular cartilage of femur, tibia and patella smooth and intact. No bone erosion.

Pus sent for Gram stain, culture and sensitivity, and AFB culture before washout.

Loculations broken with a finger. Fibrin cleared. Piece of synovium taken for culture and HPE.

Joint washed with 6 litres of normal saline until the return was clear, flexing and extending the knee to clear the recesses.

Tourniquet released at 22:38, total 40 min. Haemostasis checked before closure.

Closure

Synovium left open. 14 Fr suction drain placed in the joint, brought out through a separate stab superolaterally.

Capsule closed loosely with polydioxanone (PDS) 1. Skin closed loosely with interrupted polyamide (Ethilon) 2-0.

Dressing. Knee splint in functional position. Dorsalis pedis pulse palpable at end.

Specimens and implants

Pus: Gram stain, culture and sensitivity, AFB culture (3 containers). Synovium: 1 piece for culture, 1 piece in formalin for HPE.

No implants.

End of procedure

Estimated blood loss 50 ml. Mop, needle and instrument count correct. No intra-operative complications.

Shifted to recovery, stable. Pulse 96/min, BP 122/76 mmHg, temperature 38.2 C.

Post-op orders

Inj cefazolin 2 g IV 8-hourly; to be changed on culture report.

Temperature and pulse 4-hourly.

Drain output charted; remove at 24 to 48 h.

Straight-leg raising and quadriceps setting from tonight. Active knee bending from tomorrow when comfortable. Splint for 1 week except during exercises.

CRP and TLC on day 3. Consultant review for repeat washout if fever and swelling do not settle.

Signature

Dr A., JR-2, Orthopaedics. Reg. no. ________. 03/08/2026, 23:05.

Must document for this operation

  • Whether cultures were taken before antibiotics, and the time of the first antibiotic dose. Cultures taken after antibiotics may be negative, and the treating team needs to know how to read the culture report.
  • Appearance of the fluid, synovium and cartilage (with the Gächter stage if used). The state of the cartilage predicts the outcome and guides any later reconstruction.
  • Volume and type of irrigation fluid. Shows that a full washout was done, which matters if a repeat washout is needed.
  • All specimens sent and to which laboratory. Missing a TB or fungal culture at the first washout often means a second operation to get tissue.
  • Nerves at risk for the approach used and their status at the end. Each approach has a named nerve at risk; a post-op deficit is easier to explain if the note shows it was protected.
  • Drain, splint position and exercise plan. Prolonged immobilisation causes stiffness; the ward team needs a clear plan.

Common mistakes in these notes

  • Writing 'pus drained' with no volume, no cartilage description and no stage.
  • No record of which specimens were sent, or antibiotic given before cultures without saying so.
  • No irrigation volume.
  • Leaving out the splint position and the start of movement.
  • For the hip, not stating the approach and how the capsule was opened, which matters for femoral head blood supply.

Indian practice and paperwork

  • Tissue and pus not sent to the laboratory, and contaminated dressings, are disposed of as yellow category bio-medical waste. Discarded formalin is chemical waste, yellow (f). (Bio-Medical Waste Management Rules 2016, DGHS/CPCB guidelines)
  • 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, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; 2027, Ch 24, Infectious arthritis: Tables 24.6-24.8, Techniques 24.1-24.21 (drainage of tarsal joints, ankle, knee, hip, shoulder, elbow), pp. 827-838.
  • Chapman MW, James MA, eds. Chapman's Comprehensive Orthopaedic Surgery. 4th ed. Jaypee Brothers; 2019, Ch 55, Septic arthritis (Okoroafor U, Kaar S, Greenberg DD), e-book PDF pp. 1077, 1079-1082.

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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