DESCRIPTION OF OPERATION: The patient was placed on the operating table in the supine position. After establishment of adequate spinal anesthesia, Foley catheter was placed. Confirmed prophylactic antibiotics were previously given intravenously. The patient was placed in the lateral position. All bony prominences were well padded and an axillary roll placed. Pelvis was secured with Montreal Universal Hip Positioner. This was somewhat difficult due to the patient's exogenous obesity. Firm stabilization was achieved and good placement of axillary roll was achieved. Under ultraviolet lights, the lateral aspect of the hip and thigh were shaved, then sterilely prepped and draped in the usual sterile fashion. The patient was brought into the enclosed environment laminar flow suite with all personnel utilizing body exhaust suits, and an additional sterile draping was carried out. The site of skin incision was isolated with Betadine-impregnated Vi-Drape. The skin was incised parallel with the proximal femur curving gently posteriorly, proximally, and deepened to the level of the fascia of the thigh, which was divided along its fibers. The gluteus maximus was carefully split proximally. Piriformis was identified, released. Remaining rotators left attached to the capsule, which was reflected posteriorly, protecting the sciatic nerve. The hip was then dislocated without difficulty. The femoral neck was transected along a line determined on preoperative templating and acetabulum exposed circumferentially. Acetabulum was sequentially reamed until excellent circumferential contact was achieved at 57 mm of reaming. This was noted to be larger than the preoperative templated size. The acetabulum had some flare and did not provide rim fit until it was reamed to 57 mm. A 58 mm trial provided excellent rigid fit. Significant bone remains in anterior and posterior columns. Fovea was cleared free of soft tissues. Cysts were curetted free of soft tissue and were filled with bone graft harvested from the resected femoral head. Graft compacted with reamer run in reverse. A 58 mm shell was impacted into position and excellent fit achieved. Attention was then turned to the femur. Axial line of the femur was determined with the starting reamer and then broached up through including a #7 broach; this provided rigid fit. The patient had extremely dense cancellous bone and it was felt the #8 rasp likely could not be seated. Trial reduction was carried out and excellent stability achieved to a zero length 32 mm head and neck. Hip was reduced and excellent motion achieved. Hip could be forward flexed to 90 degrees, internally rotated to 90 degrees at mid flexion position, 80 degrees at full 90 degrees of flexion, could be forward flexed 110 degrees. The hip could be externally rotated and extended and abducted without impingement, subluxation or dislocation with either extreme of motion. The trial components were removed. A hole eliminator placed in the acetabulum, permanent liner locked into position after irrigating and drying the acetabular shell. A #7 HA stem was impacted on the femur with firm fit and rigid fit achieved. A zero length head was then impacted on the cleansed and dried Morse taper and hip re-reduced and range of motion confirmed. Excellent stability was achieved. The patient was given heparin 2000 units intravenously prior to hip reduction. The hip was thoroughly irrigated and inspection showed excellent hemostasis had been established. The posterior capsule was reapproximated to the posterior aspect of the greater trochanter through drill holes through bone with #1 Ethibond suture into the gluteus minimus proximally. The fascia of the thigh was reapproximated with interrupted #1 Ethibond suture in figure-of-eight fashion. Superficial layers were closed with 0 and 2-0 Vicryl sutures, and the skin was reapproximated with skin staples. A sterile compressive dressing was placed. The patient was transported to the recovery room awake and in stable condition.
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