OT notes · Orthopaedics

Total hip replacement

Usual anaesthesia
Spinal (subarachnoid block), with or without epidural
Position
Lateral decubitus with pelvic supports (posterior or lateral approach); supine for direct anterior approach
Setting
elective

Operative note template for primary total hip replacement, with a filled example for an uncemented THR through the posterior approach for avascular necrosis of the femoral head under spinal anaesthesia.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • dislocation
  • leg length difference
  • fracture of the femur or acetabulum during surgery
  • sciatic or femoral nerve injury
  • injury to major vessels (rare)
  • deep infection needing further surgery
  • deep vein thrombosis and pulmonary embolism
  • heterotopic bone formation and stiffness
  • loosening, wear and need for revision

Pre-operative details for this operation

  1. Side and diagnosisprimary OA, avascular necrosis (stage), inflammatory arthritis, DDH, post-traumatic, failed fixation
  2. Pre-op leg length and deformitytrue and apparent shortening in cm, fixed flexion / adduction
  3. X-rays and templatingAP pelvis, lateral hip; planned cup size, stem size, neck cut level above lesser trochanter, offset
  4. Spine and pelvic mobilitystiff or fused spine noted, as it changes cup position
  5. Previous implants to removetype; extraction set available
  6. Anticoagulant / antiplatelet statusdrug, last dose
  7. Blood grouped and cross-matchedunits reserved

Anaesthesia and position

  1. AnaesthesiaSpinalCombined spinal-epiduralGeneral
  2. PositionLateral decubitusSupinepelvis held square with supports on pubic symphysis / ASIS and sacrum, not over femoral triangle; peroneal nerve and bony points padded
  3. ApproachPosterior / posterolateralDirect lateral (Hardinge)AnterolateralDirect anterior
  4. Tranexamic aciddose, route, time, if given
  5. TourniquetNot applicable

Operative findings

  1. Femoral headcollapse, cartilage loss, osteophytes; diameter
  2. Acetabulumcartilage loss, cysts, osteophytes, medial wall, bone defects
  3. Bone qualityGoodOsteoporotic
  4. Joint fluid / synoviumif abnormal or infection suspected, sent for culture / HPE

Procedure (steps)

  1. Painting and drapingantiseptic, U-drape sealing perineum, foot in stockinette
  2. Incision and deep exposurelength; fascia lata and gluteus maximus split; sciatic nerve palpated and protected
  3. Short external rotators and capsuletagged, divided at insertion, capsule kept for repair
  4. Leg length referencepin in ilium and mark on trochanter, distance in mm; or other device
  5. Dislocation and neck cutlevel above lesser trochanter as templated (mm); head removed and kept for graft if needed
  6. Acetabular exposurelabrum, pulvinar and osteophytes removed; transverse acetabular ligament identified
  7. Acetabular reamingfirst and last reamer size; medial wall intact; cysts grafted
  8. Cup insertionUncemented press-fitUncemented with screwsCementedsize; inclination about 40-45 degrees and anteversion, referenced to transverse ligament; screw number, lengths and quadrant
  9. Linermaterial, inner diameter, neutral or elevated rim and its position
  10. Femoral preparationbox osteotome, canal reamer lateralised, broach sizes, anteversion
  11. Trial reductionstem, neck length, head size; stability in extension with external rotation, flexion 90 with internal rotation, position of sleep; shuck test; leg length and offset versus reference
  12. Stem insertionUncemented press-fitCementedsize; if cemented: plug, lavage, cement packets, gun, pressurisation; BP / SpO2 at cementing
  13. Head and final reductiontaper cleaned and dried; head material, diameter, neck length; final stability; calcar and trochanter checked for fracture
  14. Intra-operative X-ray / C-armNot neededDone, images savedif size, position or leg length uncertain

Closure, drains and dressing

  1. Capsule and short external rotatorsrepaired to trochanter through drill holes with heavy non-absorbable suture
  2. Gluteus maximus insertion / quadratus femorisrepaired if divided
  3. DrainNoneClosed suction drain deep to fascia
  4. Fascia lataclosed with hip in about 10 degrees of abduction
  5. Subcutaneous tissue and skinsuture material or staples
  6. Neurovascular status at enddistal pulses; ankle and toe dorsiflexion and plantarflexion (sciatic) and knee extension (femoral) when block allows
  7. Leg lengths at endcompared at knees / heels on table

Specimens and implants

  1. Acetabular shell / cuptype, outer diameter, make, lot / batch number, sticker
  2. Acetabular screwsnumber and lengths, lot / batch number, sticker
  3. Linermaterial, inner diameter, rim type, lot / batch number, sticker
  4. Femoral stemdesign, size, offset, cemented / uncemented, lot / batch number, sticker
  5. Femoral headmaterial, diameter, neck length, lot / batch number, sticker
  6. Bone cement and plug (if used)packets, weight, plain or antibiotic-loaded, lot / batch number, sticker
  7. Femoral head specimenDiscarded as biomedical wasteSent for HPEUsed as bone graft

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Vitals and limb checkpulse, BP, distal pulses, foot and toe movement, sensation; hourly for 4 hours then 4-hourly
  2. Positionhip in about 15 degrees of abduction; triangular pillow after posterior approach; pillow between knees when turning
  3. Check X-rayAP pelvis and lateral of operated hip
  4. Analgesiadrug, dose, frequency; epidural if placed
  5. Mobilisation and weight bearingwalker from POD 0 or 1; cemented: as tolerated; uncemented: as per surgeon, as tolerated or protected for 6 weeks
  6. Dislocation precautionsif prescribed: avoid deep flexion with adduction and internal rotation; raised toilet seat
  7. Thromboprophylaxisas per unit protocol
  8. Drainremoval time if placed
  9. Hb on POD 1
  10. Suture removal and follow-upat about 2 weeks; X-ray review at 6 weeks

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. R.J., 46 years, avascular necrosis of the left femoral head with collapse and secondary arthritis, history of alcohol use, 2 cm shortening, planned for elective uncemented left THR.

Case details

Date: 22/07/2026. Elective arthroplasty list. OT 4 (laminar flow).

In OT 08:40. Spinal with epidural catheter 08:55. Skin incision 09:35. Skin closed 11:25.

Surgeon: Dr C. (consultant). First assistant: Dr A. (3rd-year resident, Orthopaedics), did exposure, femoral preparation under supervision, and closure. Second assistant: Dr B.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: left hip AVN with femoral head collapse and joint space loss, pain at rest, walking limited to 100 m. Right hip normal on X-ray.

Pre-op: 2 cm true shortening of left leg, fixed flexion 15 degrees. Templated cup 52 mm, stem size 12, neck cut 12 mm above lesser trochanter.

Hb 13.6 g/dl. Blood group B positive, 2 units cross-matched.

Consent: general, procedure-specific and anaesthesia consent taken in Telugu from patient, wife as witness. Dislocation, leg length difference, nerve injury and infection explained.

Left hip marked. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 09:15, before skin incision.

Anaesthesia and position

Spinal anaesthesia with epidural catheter. Right lateral decubitus, left side up, pelvis square with supports on pubic symphysis and sacrum, right peroneal area padded. Table level.

Parts painted with chlorhexidine-alcohol, U-drape applied, foot in stockinette, draped.

Procedure

Posterolateral approach. 15 cm curved incision centred on the greater trochanter. Fascia lata divided, gluteus maximus split.

Sciatic nerve palpated and protected. Piriformis and obturator internus tagged with braided polyester No. 2 and divided at insertion with upper half of quadratus femoris. Capsule divided at femoral attachment and kept.

Steinmann pin in ilium above acetabulum, mark on greater trochanter: reference distance 48 mm with leg in neutral.

Hip dislocated posteriorly. Head collapsed superolaterally, cartilage worn. Neck cut 12 mm above lesser trochanter. Head kept on the table.

Labrum, pulvinar and ligamentum teres excised, osteophytes removed. Transverse acetabular ligament seen. Reamed from 46 mm to 51 mm, medial wall intact, bleeding subchondral bone. One small superior cyst curetted and grafted with reamings.

Uncemented porous-coated cup 52 mm press-fit (1 mm over last reamer), about 42 degrees inclination and 20 degrees anteversion, lower edge parallel to transverse ligament. One 6.5 mm screw, 30 mm, in the posterosuperior quadrant, finger in sciatic notch. Cup stable. Rim osteophytes removed.

Highly cross-linked polyethylene liner, neutral, 32 mm inner diameter, seated and locked.

Femur delivered with hip flexed, adducted and internally rotated. Box osteotome, canal reamer lateralised. Broached to size 12 in native anteversion, axially and rotationally stable.

Trial reduction with size 12 stem, standard offset, 32 mm head +0 neck: stable in extension with 40 degrees external rotation, 90 degrees flexion with 50 degrees internal rotation, and in position of sleep. Shuck test 2 mm. Pin-to-mark distance 60 mm, lengthening of about 12 mm.

Uncemented stem size 12 impacted to broach level. Calcar and trochanter checked: no fracture. Taper cleaned and dried. Ceramic head 32 mm +0 neck impacted. Hip reduced and stable through full range.

Closure

Posterior capsule and short external rotators repaired to the greater trochanter through two drill holes with braided polyester No. 2. Quadratus femoris repaired.

No drain. Fascia lata closed with polyglactin 910 (Vicryl) No. 1 with hip in 10 degrees of abduction. Subcutaneous tissue with Vicryl 2-0. Skin with staples. Sterile dressing. Abduction pillow applied.

Specimens and implants

Uncemented cup 52 mm; one acetabular screw 6.5 x 30 mm; highly cross-linked polyethylene liner 32 mm, neutral; uncemented stem size 12, standard offset; ceramic head 32 mm, +0 neck.

Make and lot / batch numbers as on the stickers. All 5 stickers pasted on the implant page of the case sheet and entered in the OT implant register.

Femoral head sent for HPE to confirm AVN. No cement. No tourniquet.

End of procedure

Estimated blood loss 500 ml (suction 300 ml + mops). No transfusion in OT.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Left leg about 8 mm shorter than right at the heels on table, as expected from 2 cm pre-op shortening and 12 mm lengthening on the pin-to-mark check. Left foot warm, dorsalis pedis pulse palpable, capillary refill under 2 seconds. Foot and knee movement to be checked as the block wears off.

Shifted to recovery in stable condition. Pulse 82/min, BP 126/78 mmHg.

Post-op orders

Pulse, BP, distal pulses and ankle and toe movement hourly for 4 hours, then 4-hourly. Report foot drop at once.

Abduction pillow. Avoid flexion beyond 90 degrees, crossing legs and inward turning of the leg.

Epidural infusion and other analgesia as per anaesthetist (drug, dose and times written on the drug chart).

Thromboprophylaxis as per unit protocol.

Check X-ray AP pelvis and lateral left hip. Hb on POD 1.

Stand and walk with walker from POD 1, weight bearing as tolerated.

Staples out at 2 weeks. X-ray review at 6 weeks.

Signature

Dr A., JR-3, Orthopaedics, for Dr C. Reg. no. ________. 22/07/2026, 11:40.

Must document for this operation

  • Approach used and whether the posterior capsule and rotators were repaired. The approach affects dislocation risk and the choice of approach at revision.
  • Cup size, position (inclination and anteversion), fixation, and number and position of screws. Cup position is the first thing reviewed after a dislocation, and screws must be planned for at revision.
  • Liner material and inner diameter, head material, diameter and neck length. A revision for wear or dislocation may only need a head and liner change if matching parts are known.
  • Every component with make and lot / batch number, with stickers pasted. Needed for implant recall, the discharge summary and the joint registry.
  • Leg length measured at trial and at end, with the method. Leg length difference is a common complaint and a common reason for legal claims after THR.
  • Cemented or uncemented fixation, cement lot, and any BP or SpO2 change at cementing. Cement is an implant and a cement reaction must be on record.
  • Sciatic and femoral nerve function and distal pulses at the end. A nerve palsy found later cannot be timed without a baseline record.

Common mistakes in these notes

  • Writing 'THR done' with no cup, liner, stem or head details.
  • Not recording cup screws, which the revision surgeon must plan to remove.
  • No leg length check recorded.
  • Not recording whether the posterior soft tissues were repaired.
  • Stickers of only some components pasted.
  • No record of foot movement when the block wears off.

Indian practice and paperwork

  • Record the batch and serial number of every component in the case sheet; NABH also expects them in the OT implant master logbook and the discharge summary. (NABH Hospital Standards 5th ed., MOM.10(d))
  • The Indian Joint Registry of the Indian Society of Hip and Knee Surgeons (ISHKS) is voluntary; its form asks for implant details, so a complete sticker page makes entry easy. (ISHKS registry reports (AAHKS news 2019; PMC3796925))
  • In a Stanford audit of revision arthroplasty (first author also affiliated with a Pune hospital), the primary op note was available in 47 percent and implant stickers in 32 percent of cases. (Electricwala AJ et al., Open Orthop J 2016;10:725-731)

Sources

  • Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; copyright 2027, Ch 4 Arthroplasty of the hip: preparation and draping, THA through posterolateral approach (Technique 4.2), component implantation (Techniques 4.3 to 4.6), soft-tissue repair and closure, postoperative management, pp. 219-235, 328-329.
  • Azar FM, Beaty JH, eds. Campbell's Core Orthopaedic Procedures. 2nd ed. Elsevier; 2024, Technique 1 Total hip arthroplasty: standard posterolateral approach; Technique 2 Direct anterior approach (Harkess JW, Crockarell JR), pp. 1-11.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision; redose after 4 h. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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