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xx.xx.xxxx.                                                 Preoperative agreement.

Patient хххх, хх y.o., (case № хххх) admitted at хх.хх.хxxх. Diagnosis: Short stature.

Because of patient’s insistence the surgery of tibias and fibulas osteotomy for both lower legs, external fixations for both lower legs will be performed ___________.

In post-operative period lengthening of lower legs (distraction by frames) on x cm is planned. Increasing of the height should be performed by lengthening of lower legs ___________.

Contraindications for the planned surgery while consulting by anesthesiologist were not revealed.

Patient is informed about plan of anesthesia and surgery, is warned about possible complications while anesthesia, surgery, post-operative period (including blood loss ___________, nerve palsy ___________, damages of vessels ___________, infection ___________, osteomyelitis ___________, mal-union ___________, non-union ___________, bone deformity ___________, discrepancy of the lengths of the legs ____________, patella subluxation ___________, knee joint subluxation ___________, knee joint stiffness ___________, ankle joint stiffness ___________, breakage of parts of frames or implants ___________, dermatitis ___________, exacerbation of chronic diseases ___________).

In case of nerve troubles, joints stiffness, hypotrophic regenerates lengthening or correction will be slowed down or arrested ___________.

During treatment to walk without crutches or walker in the apartment only is recommended ___________.

Patient is informed about possible afterwards of the planned surgery in early and remote postoperative period (synovitis, arthritis of joints of lower limbs, increasing of plant-feet, scars from pins and wires, increasing of osteochondrosis) ___________.

Patient is agreed that applying method of treatment can’t totally exclude the possibility of side effects and complications, caused by anatomical and physiological features of the patient. Patient is agreed for the surgery, undertakes to perform the recommendations from the stuff. In case of complications while operation, the surgery plan and anesthesia can be changed.

Chief of orthopedic department and patient approve the plan of surgery.

Patient is agreed for the operation.

 

 

Patient                                                                               ___________ хххх

 

 

Doctor in clinic                                                                   ___________ хххх

 

 

Chief of orthopedic department                                         ___________ хххх