DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Failed right hip open reduction and internal fixation.
POSTOPERATIVE DIAGNOSIS: Failed right hip open reduction and internal fixation.
OPERATIONS PERFORMED: Complicated right total hip replacement and removal of failed compression hip screw.
SURGEON: John Doe, MD
ANESTHESIA: Epidural and general endotracheal tube.
ESTIMATED BLOOD LOSS: 900 mL.
DESCRIPTION OF OPERATION: The patient was treated with an epidural catheter prior to entering the operating room. He was brought to the operating room and received vancomycin 1 gram and Ancef 1 gram prior to any surgical incisions. He also underwent general anesthesia with placement of an endotracheal tube. He was placed in the lateral decubitus position with the right side up and prepped and draped in standard fashion. Initial incision was made over the lateral aspect of the right hip and dissection was carried down through the iliotibial band to the lateral aspect of the hip. It was difficult to find the plate due to excessive heterotopic ossification that had grown over the proximal three-quarters of the plate itself. Only the distal quarter of the plate was visualized. All this excess bone was removed from the lateral aspect of the plate and it became apparent that all six screws along the lateral side of the plate had fractured at the junction between the plate and the bone. Any excess heterotopic bone was removed from around the plate, and with some ease, the lateral plate was removed from the femur, leaving the compression hip screw in place. With difficulty, all the broken screws were located with the combination of small osteotome and a rongeur, and using a screw removal set, one by one, the screws were removed intact along the length of the femoral stem.
Attention was then turned to exposing the acetabulum through a posterolateral approach. The acetabulum was then exposed. The compression hip screw was swimming in the femoral head, which it had basically cored out to an eggshell by this time. This was removed proximal to distal rather than pulling it out the lateral aspect of the femur. The femoral head was then removed from the acetabulum, appeared to have a large segment of femoral neck on it. The acetabulum was then exposed and beginning with the size 55 reamer, reaming was continued up to a size 60. The patient had extremely soft bone and a size 62 cup was then impacted into place followed by the placement of two 65 cancellous screws. Both of these screws had excellent bite. A 32 mm inner diameter neutral trial was then put in place.
Attention was then turned to the proximal femur, and again, extensive heterotopic ossification was noted around the proximal femur. It was difficult to tell exactly where true cortical bone began and heterotopic bone ended. What was felt to be a lesser trochanter was located and any excessive bone was removed from around this. Reaming was continued from a size 8 up to a size 19 with good proximal bite. Then, a column reaming was begun up to a size 24D followed by milling. During the milling procedure, a small crack was noted in the anterior cortex. This was fixed using a single cerclage wire. Trial initially beginning with a standard 36 neck and a +9 head was utilized. This left significant shortened extremity with significant instability. It was determined that the only implant that would provide stability for the patient would be the use of the 12 x 19 36+21 calcar replacing neck posterolateral, and this required conversion to a long stem, and using both the semi-rigid and straight reamers, appropriate reaming was accomplished for the long stem S-ROM so we could use this calcar-replacing stem. Trails were all removed. A 36 mm inner diameter 10 degree lipped liner was then placed in appropriate position in the 62 mm cup.
Attention was then again turned to the femur where a 24D large stem sleeve was then impacted into appropriate position for excellent fixation. Based on trialing, an extra 25 degrees in anteversion was dialed into the stem component. The sleeve had been put in at approximately 10 degrees of retroversion, and after the 25 degrees of anteversion was dialed in, it appeared the patient had at least 20 degrees of normal and reproduced anteversion on the stem. This was impacted into place with excellent bite distally all the way down until Morse taper engaged and a +12, 36 mm head was then trialed providing excellent stability. The trial was then removed and finally the +12 head was impacted into place with the hip reduced. The patient was able to abduct. The leg lengths appeared to be equal at that point. Flexion to 90 degrees and internal rotation to 70 did not reproduce any dislocation.
The wound was then thoroughly irrigated. The Cell Saver was continued postoperatively with the use of an OrthoPAT drain placed onto the iliotibial band. The vastus lateralis and short external rotators and posterior capsule were closed using 5 Ethibond. The iliotibial band was closed using 0 Vicryl, subcutaneous tissues using 2-0 Vicryl and the skin using staples. The patient was then dressed with Xeroform, 4 x 4s, ABDs and paper tape. The OrthoPAT drain was then hooked up to what was used as a Cell Saver during the course of the operation. The patient did receive 350 mL of his own blood back in the operating room and continued to utilize the OrthoPAT postoperatively. The patient was then transferred to the PACU in good condition.