Hip Arthroplastry Procedure Note

OVERALL_INSTRUCTIONS

Chief Complaint

Consult Letter Template

Template

Patient Name: [Patient Name] Date of Surgery: [Date of Surgery] Time In/Out of OR: [Time In/Out of OR] Surgeon(s): [Surgeon(s)] Assistants: [Assistants] Anesthetist: [Anesthetist] Scrub/Circulating Nurse: [Scrub/Circulating Nurse] Procedure Performed: [Procedure Performed] Laterality: [Laterality] Patient Positioning: [Patient Positioning] Tourniquet Details: [Tourniquet Details] Anesthesia Type: [Anesthesia Type] Pre-op Diagnosis: [Pre-op Diagnosis] Post-op Diagnosis: [Post-op Diagnosis] Intraoperative Findings: [Intraoperative Findings - for example: Severe degenerative changes of the femoral head and acetabulum with full-thickness cartilage loss. Osteophytes present circumferentially. No signs of infection.] Procedure Description: [Procedure Description - for example: A standard posterolateral approach to the left hip was performed. The short external rotators were identified and tagged. The hip was dislocated without difficulty. The femoral head was resected at the appropriate level. The acetabulum was sequentially reamed to 54 mm, achieving a good bleeding cancellous bed. A 56 mm uncemented acetabular shell was impacted in appropriate anteversion and inclination, with excellent initial stability. One cancellous screw was placed for supplemental fixation. A neutral polyethylene liner was inserted. Attention was then turned to the femur. The canal was broached sequentially to size 10 with good axial and rotational stability. A size 10 uncemented femoral stem was inserted. A 36 mm +0 ceramic head was placed. The hip was reduced, demonstrating excellent stability through a full range of motion with appropriate leg length and offset. Final fluoroscopic image confirmed acceptable component positioning. The external rotators and capsule were repaired. The wound was irrigated thoroughly and closed in layers. A sterile dressing was applied.] Implants Used: * [Implant 1 Details] * [Implant 2 Details] * [Implant 3 Details] * [Implant 4 Details] Intraoperative Imaging: [Intraoperative Imaging Details] Reduction and Alignment: [Reduction and Alignment Details] Neurovascular Exam: * Pre-op: [Pre-op Neurovascular Exam Details] * Post-op: [Post-op Neurovascular Exam Details] Drains/Lines Placed: [Drains/Lines Placed] Estimated Blood Loss: [Estimated Blood Loss] Specimens Sent: [Specimens Sent] Counts: [Counts] Intraoperative Complications: [Intraoperative Complications if any] Disposition: [Disposition - for example: Patient transferred to PACU in stable condition] Post-Operative Plan: a. Vital Signs Monitoring: [Vital Signs Monitoring Details] b. Pain Management: [Pain Management Details] c. Fluid Management: [Fluid Management Details] d. Antibiotics: [Antibiotics Details] e. Thromboprophylaxis: [Thromboprophylaxis Details] f. Wound Care: [Wound Care Details] g. Activity and Weight-Bearing Status: [Activity and Weight-Bearing Status Details] h. Diet: [Diet Details] i. Investigations/Follow-Up Labs: [Investigations/Follow-Up Labs Details] j. Review/Follow-Up: [Review/Follow-Up Details] k. Additional Notes: [Additional Notes like referrals to PT, OT, etc. ] Signature: [Signature]