OT notes · Orthopaedics

Corrective osteotomy (proximal femoral / pelvic / high tibial / supracondylar humeral / digital)

Usual anaesthesia
General or single-shot spinal anaesthesia (no post-op epidural for tibial osteotomy, so compartment checks are not masked)
Position
Supine on a radiolucent table, bump under the same-side buttock; limb draped free with hip and ankle in the image field
Setting
elective

Operative note template for a corrective (realignment) osteotomy at any site, with a filled example for a medial opening wedge high tibial osteotomy for varus medial compartment knee osteoarthritis.

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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

  • under-correction or over-correction
  • fracture of the opposite (hinge) cortex or into the joint
  • delayed union or non-union
  • loss of correction or implant failure
  • compartment syndrome
  • injury to nerves and vessels (popliteal vessels, peroneal nerve)
  • infection and wound breakdown over the plate
  • deep vein thrombosis
  • change in patellar height (tibial osteotomy)
  • later plate removal or joint replacement

Pre-operative details for this operation

  1. Site and type of osteotomyMedial opening wedge HTOLateral closing wedge HTOProximal femoral varus / derotationPelvic (Salter / Pemberton)Supracondylar humeral (cubitus varus)Digital
  2. Diagnosis and deformitycause (degenerative, post-traumatic, Blount, Perthes, malunion); plane(s) of deformity
  3. Measurements on standing long-leg X-raymechanical axis deviation (mm), MPTA / LDFA or neck-shaft angle, joint line obliquity
  4. Correction plannedtarget point (e.g. lateral tibial spine), angle in degrees, osteotomy length and wedge size in mm
  5. Other compartments / jointslateral compartment and patellofemoral joint status; ligament laxity (MCL, LCL, ACL)
  6. Implants and graft readyplate system and sizes, wedge trials, bone graft or substitute

Anaesthesia and position

  1. AnaesthesiaGeneralSpinal (single shot)
  2. PositionSupine, bump under ipsilateral buttockSupine, hip bumped (femoral)
  3. TourniquetThigh tourniquetNot usedpressure, inflation and deflation times
  4. Image intensifiercentre of femoral head, knee and ankle all seen before draping

Operative findings

  1. Bone qualitynormal / osteoporotic
  2. Soft-tissue tensione.g. MCL tight, needed release
  3. Hinge cortex after openingIntactCrack, undisplacedFracture, displacedfor HTO: Takeuchi type if fractured
  4. Alignment achievedwhere the alignment rod or line crosses the joint on image

Procedure (steps)

  1. Incisionsite and length
  2. Deep exposurefor HTO: sartorius fascia and superficial MCL incised and released subperiosteally to the back of the tibia; patellar tendon protected
  3. Protection of neurovascular structuresblunt retractor behind the bone along the osteotomy line
  4. Osteotomy level marked / guide wiredistance from joint line; guide pin checked on image
  5. Bone cutOscillating saw + osteotomesGigli sawChisel for blade platehinge left intact (width in mm); biplanar cut under tubercle for HTO
  6. Correctionopening with lamina spreaders / wedge removal / varus and derotation; size of wedge in mm; degrees of rotation
  7. Alignment checkalignment rod from hip centre to ankle centre on image; where it crosses the knee
  8. Bone graftAllograft wedgeAutograftBone substituteNone (closing wedge)
  9. Fixationplate type, holes, screws above and below (locking / cortical), K-wires; final image in two planes

Closure, drains and dressing

  1. Tourniquet released and haemostasistotal tourniquet time
  2. DrainSuction drainNone
  3. Deep layerperiosteum / MCL / pes over the plate; muscle reattached
  4. Subcutaneous tissue and skinsuture used
  5. Dressing / castLight compressive dressingLong-leg castHip spica

Specimens and implants

  1. Plate and screwsmake, type, size, number of screws, batch/lot, sticker pasted
  2. Bone graft or substitutetype, size, batch, sticker
  3. SpecimensNoneResected wedge used as graft

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. Compartment checkspain on passive stretch, tense leg, toe movement and sensation every 4 to 6 hours for 24 to 48 hours
  2. Elevation and icelimb elevated
  3. Drainremove at 24 hours unless output more than 50 ml per shift
  4. Analgesiadrug, dose, frequency; avoid epidural
  5. DVT prophylaxisdrug, dose and duration; foot pump in hospital
  6. Weight bearingpartial (about 20 kg) with walker for 6 weeks after locked-plate HTO; other sites as per fixation
  7. Knee range of motionfrom POD 1; no brace needed after locked-plate HTO
  8. X-rayscheck X-ray; standing long-leg X-ray at follow-up to confirm alignment
  9. Follow-upsuture removal, union check at 6 weeks

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.J., 44 years, farmer, medial knee pain for 2 years, right genu varum. Standing long-leg X-ray: mechanical axis 28 mm medial to knee centre, MPTA 83 degrees, medial joint space narrowed, lateral compartment normal.

Case details

Date: 10/08/2026. Elective right medial opening wedge high tibial osteotomy. OT 2.

In OT 09:00. Tourniquet up 09:35. Tourniquet down 10:55. Out of OT 11:20.

Surgeon: Dr A. (consultant, orthopaedics). Assistant: Dr B. (3rd-year resident). Anaesthetist: Dr C. Scrub nurse: Sr D.

Indication and pre-op

Indication: symptomatic medial compartment osteoarthritis with tibia vara (MPTA 83 degrees), varus under 15 degrees, lateral and patellofemoral compartments normal, ligaments stable.

Plan: correct mechanical axis to the lateral tibial spine. Planned correction 9 degrees. Osteotomy line 60 mm long, so planned opening about 9.5 mm; open to 10.5 mm to allow for saw cut.

Consent: general, procedure-specific and anaesthesia consent taken in Marathi from patient. Under or over correction, hinge fracture, compartment syndrome and later plate removal explained.

Right leg marked. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 09:20, completed before tourniquet inflation.

Anaesthesia and position

Spinal anaesthesia, single shot, no epidural catheter.

Supine on radiolucent table, bump under right buttock, patella facing up. Hip, knee and ankle centres seen on image before draping.

Thigh tourniquet, 300 mmHg after exsanguination. Parts painted with povidone-iodine and draped.

Procedure

Longitudinal medial incision 9 cm, starting 15 mm below the joint line midway between the tibial tubercle and the posterior border of the tibia.

Sartorius fascia and superficial MCL incised in line with the skin, just anterior to the hamstrings, and released subperiosteally to the back of the tibia. Blunt Hohmann retractor passed behind the tibia along the osteotomy line. Patellar tendon protected with a retractor.

Plate template placed and osteotomy level marked. Biplanar osteotomy marked: posterior two-thirds transverse, anterior one-third at about 120 degrees ending above the tubercle, leaving 12 mm of tubercle.

2 mm Steinmann pin placed along the planned line under image, aimed at the proximal tibiofibular joint, 15 mm from the lateral joint surface.

Posterior cut with oscillating saw below the pin, posterior cortex fully cut. Anterior cut behind the tubercle, bicortical. Deepened with graduated osteotomes leaving the lateral 1 cm intact.

Osteotomy opened slowly with two flat lamina spreaders in the posterior part. Metal wedge trial 10 mm inserted.

Findings: good bone quality. Lateral hinge intact on image. Distal MCL fibres tight, small release done.

Alignment rod from hip centre to ankle centre crossed the knee at the lateral tibial spine. Correction accepted.

Trial replaced with a 10 mm allograft wedge, thicker side posterior. Remaining gap filled with allograft chips.

Medial proximal tibial locking plate applied. Two proximal locking screws placed. One 4.5 mm cortical screw below the osteotomy to bring the plate to bone. Remaining two shaft holes with bicortical locking screws, then the last proximal locking screws. Final image AP and lateral: plate and screws satisfactory, hinge intact, slope unchanged.

Closure

Tourniquet released at 10:55, total 80 min. Haemostasis secured. Medium suction drain placed.

Proximal periosteum and MCL layer closed over the plate, deep subcutaneous tissue over the distal plate, with polyglactin 910 (Vicryl) 0 and 2-0. Skin closed with subcuticular suture. Light compressive dressing. No brace.

Specimens and implants

Medial proximal tibial locking plate with proximal locking screws, one 4.5 mm cortical screw and two bicortical locking screws. Allograft wedge 10 mm and allograft chips. Make, batch and serial numbers recorded; stickers pasted.

No specimen.

End of procedure

Estimated blood loss 150 ml. No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Shifted to recovery in stable condition. Pulse 76/min, BP 124/80 mmHg. Dorsalis pedis pulse felt, toes warm.

Post-op orders

Compartment check (pain on passive toe stretch, tense calf, toe sensation) every 4 hours for 48 hours. Inform on-call resident at once if pain is out of proportion.

Limb elevated. Foot pump on the right leg while in bed.

Drain removal at 24 hours unless output more than 50 ml per shift.

DVT prophylaxis: aspirin as per unit protocol for 4 weeks.

Partial weight bearing (about 20 kg) with walker for 6 weeks. Knee bending from POD 1.

Check X-ray right knee AP and lateral on POD 1. Standing long-leg X-ray at 6 weeks.

Signature

Dr B., JR-3, Orthopaedics, for Dr A. Reg. no. ________. 10/08/2026, 11:30.

Must document for this operation

  • The pre-op plan: deformity measurements, target point, planned angle and wedge size. Under or over correction is judged against the plan, so it must be in the note.
  • The correction actually achieved and how it was checked on the image. If the result is poor, this shows whether the plan or its execution was the problem.
  • State of the hinge cortex and any fracture. A hinge fracture changes weight bearing and follow-up, and the ward team must know.
  • Plate, screws and graft with stickers. The plate is often removed later or at knee replacement, and the next surgeon needs the system and screw types.
  • Tourniquet time and anaesthesia type. Needed if compartment syndrome or nerve palsy follows, and an epidural would hide the warning pain.
  • Weight-bearing status and compartment-check orders. Weight bearing depends on the fixation and hinge, and compartment syndrome is a known risk.

Common mistakes in these notes

  • Writing 'HTO done' with no planned or achieved correction.
  • No mention of the hinge cortex.
  • Leaving out the graft type and size.
  • Not recording the alignment check from hip to ankle.
  • Writing 'mobilise' with no weight-bearing limit.

Indian practice and paperwork

  • Record the batch and serial number of the plate, screws and any graft in the case sheet; NABH also expects them in the OT implant master logbook and the discharge summary. (NABH Hospital Standards 5th ed., MOM.10(d))
  • In an audit of 153 orthopaedic op notes at a Mumbai hospital, tourniquet time was recorded in only 41.8 percent and closure details in 17 percent. (Tuteja S et al., Indian J Orthop 2022;56(12):2223-2227)

Sources

  • Wiesel SW, Albert TJ, eds-in-chief. Operative Techniques in Orthopaedic Surgery. 3rd ed. Vol 1. Wolters Kluwer, Adult Reconstruction, Ch 29, Proximal tibial osteotomy (high tibial osteotomy) (Reif TJ, Fragomen AT, Rozbruch SR), e-book PDF pp. 2139-2156.
  • Saghieh S, et al., eds. Operative Dictations in Orthopedic Surgery. Springer; 2013, Ch 8, Proximal femoral osteotomy (Khoury JG); Ch 39, High tibial osteotomy, closing wedge (Masrouha K); Ch 40, Medial opening wedge tibial osteotomy (Saghieh S), pp. 31-32; 145-151.
  • 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; recommended for internal fixation devices; redose after 4 h. academic.oup.com/ajhp/article/70/3/195/5112717
  • Campbell's Operative Orthopaedics 15e, Ch 2, Tourniquets, printed pp. 137-138 (pdf 162-163): tourniquet time 2 hours or less in healthy adults under 50; 175-305 mmHg satisfactory for the lower limb.

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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