DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Closed fracture of acetabulum, right posterior wall acetabulum fracture with associated posterior hip dislocation.
2. Closed posterior dislocation of hip, right, with associated posterior wall acetabulum fracture.
POSTOPERATIVE DIAGNOSES:
1. Closed fracture of acetabulum, right posterior wall acetabulum fracture with associated posterior hip dislocation.
2. Closed posterior dislocation of hip, right, with associated posterior wall acetabulum fracture.
OPERATIONS PERFORMED:
1. Open treatment of posterior or anterior acetabular wall fracture with internal fixation.
2. Open treatment of hip dislocation, traumatic, without internal fixation.
3. Insertion of wire and pin with application of skeletal traction, including removal right distal femoral skeletal traction for provisional stabilization of hip dislocation prior to definitive surgical intervention.
SURGEON: John Doe, MD
ANESTHESIA: General via endotracheal tube.
ESTIMATED BLOOD LOSS: 450 mL.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The patient was taken to the operating room. General anesthesia was induced via endotracheal tube. The patient received a gram of IV cefazolin prior to the initiation of the surgical procedure. The right lower extremity distal femoral traction pin was removed. Sterile compressive dressings were applied. The patient was transferred to the fracture table and placed in the lateral decubitus position. All bony prominences were well padded and an axillary roll was placed. The entire right lower extremity and flank were prepped and draped in sterile fashion.
Standard Kocher-Langenbeck incision centered over the greater trochanter was carried down through skin and subcutaneous tissue for approximately 25 cm. Dissection was taken to the level of the iliotibial band and the superficial fascia of the gluteus maximus, which were incised in line with the surgical incision. Blunt finger dissection technique was used to separate the first gluteus maximus, and small perforating vessels were coagulated using electrocautery. The insertional tendon of the gluteus maximus was transversely incised 1 cm from its insertion to allow better posterior retraction. The sciatic nerve was then identified at the level of the quadratus femoris and protected throughout the remainder of the case by keeping the hip in the extended abducted position with the knee flexed. The obturator internus and piriformis tendons were identified transversely and incised, tacked with #2 Ethibond suture and retracted posteriorly creating a protected muscular sling over the sciatic nerve.
Subperiosteal dissection along the posterior column and posterior wall of the lateral ilium was performed exposing the fracture dislocation of the right acetabulum. The hip fracture dislocation was addressed initially by opening the fracture, distracting the hip by placing a 6 mm Schanz pin in the lateral femur and a 5 mm Schanz pin in the lateral limb using a femoral distractor to subluxate and dislocate the hip surgically. The hip joint was then cleaned of articular debris. It was then anatomically reduced and maintained in the anatomically reduced position until fracture fixation was complete. The posterior wall fracture was then anatomically reduced and secured with two 1.6 mm K-wires. This was followed by the placement of an 8-hole 3.5 Recon plate contoured to the posterior wall and posterior columns and secured with two screws in the ischium and three screws in the lateral ilium. This buttress plate maintained anatomic reduction of the acetabulum fracture. The reduction was confirmed with two-plane image intensification under live fluoroscopy using Judet views and direct lateral radiographs demonstrating no evidence of intra-articular hardware penetration, concentric reduction of the hip dislocation and anatomic reduction of the acetabulum with stable internal fixation.
At this point, the wounds were copiously irrigated with 3 liters of pulsatile normal saline. A deep Hemovac drain was placed. The wound was closed in layers. The piriformis and obturator internus tendons were resutured with their tacking sutures. The IT band and superficial fascia of the gluteus maximus was closed with figure-of-eight 0 Vicryl suture. A subcutaneous drain was placed. The subcutaneous layer was closed with inverted 2-0 Vicryl suture and the skin with surgical staples. Sterile compressive dressings were applied. The patient was placed in a supine position and AP pelvis and Judet radiographs obtained demonstrated anatomic reduction of the acetabulum with concentric reduction of the hip dislocation with stable internal fixation of the acetabulum fracture and no evidence of intra-articular hardware penetration. The patient tolerated the procedure well and was taken to the PACU in stable condition. There were no complications.
