DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right hip osteoarthritis.
POSTOPERATIVE DIAGNOSIS: Right hip osteoarthritis.
OPERATION PERFORMED: Minimally invasive right total hip replacement.
SURGEON: John Doe, MD
ANESTHESIA: General and epidural.
ESTIMATED BLOOD LOSS: 300 mL.
FINDINGS: End-stage osteoarthritis with acetabular cyst formation and osteophytes.
DESCRIPTION OF PROCEDURE: The patient was transferred to the operative suite in good, stable condition, placed supine on the operating table, and underwent uncomplicated epidural and general endotracheal intubation. A Foley catheter was placed. IV Ancef, 2 g, was infused, and the patient was then placed in left lateral decubitus position with an axillary roll in place. Right hip and lower extremity were prepped and draped free in the usual sterile fashion utilizing Betadine.
A 4 inch incision over the posterior aspect of the greater trochanter was performed sharply. Hemostasis was obtained with electrocautery. Meticulous dissection revealed the tensor and IT band, which were opened in line with the incision. Meticulous attention was paid, bluntly identified the course of the sciatic nerve, and we were constantly aware of the nerve’s position throughout the case, especially when doing acetabular traction. A posterior capsulotomy was performed with electrocautery, and the hip was then dislocated. Corresponding to our preoperative template, approximately 20 mm above the lesser trochanter and at a 45 degree angle to the femoral shaft, the femoral neck was transected. The labrum was excised and the acetabular retractors were placed. Sequential reaming was done in 45 degrees of abduction and 25 degrees of anteversion, down to the medial aspect of the two healthy medial walls. There was some acetabular cyst formation; they were curetted out and bone grafting with bone graft from the femoral head. Copious irrigation with normal saline, bacitracin, and pulse lavage was performed.
We reamed to size 56 mm, and a 50 mm acetabular component was then impacted at 45 degrees of abduction and 25 degrees of anteversion, fully seated with excellent rim purchase noted. The osteophytes were removed with a curved osteotome. A 36 mm neutral polyethylene liner was impacted, fully engaging the locking mechanism with no soft tissue interposition. Sequential reaming was then done to 14.5 mm with good cortical purchase distally. We broached the size 15 x 15 mm large metaphyseal. We used the calcar reamer to ream the calcar anatomically. Copious irrigation of the cyst was performed and a fully porous coated 15 mm large metaphyseal component was impacted in anatomic version and fully seated medial on the calcar. We did trial reduction using +7/36 mm femoral head. Head and neck were impacted onto the proximal femur. The hip was relocated. It was found to be stable on all planes. It became unstable in full flexion, full adduction and 55 degrees of internal rotation.
On applying an axial load to the extremity, the soft tissues were well balanced. Copious irrigation with saline was performed. Hip was then dislocated. The trial component was removed. The permanent 36 mm, +7 head and neck was then impacted. Hip was then relocated. A 1/8 inch Hemovac drain exited the superolateral aspect of the hip was then placed. Copious irrigation with saline was performed. The piriformis tendon with a modified Kessler #2 Ethibond suture placed in two bone holes and piriformis fossa down to prevent postoperative dislocation. Interrupted figure-of-eight #1 Vicryl suture to approximate the tensor and IT band. Buried 2-0 Vicryl suture used to approximate the subcutaneous and dermal layers, and the skin was closed with skin staples. Adaptic, 4 x 4s and ABD dressing were applied, and paper tape. The patient tolerated the procedure well and left the operating room breathing spontaneously and in good stable condition, with an intact vascular exam and a persistent epidural block still in place.
