Hardware Removal/Implant Exchange Operative Report

Patient: [Patient name], [MRN], [DOB]

Date of Surgery: [Date of surgery]

Start/End Times: [Start time]–[End time]

Facility/Location: [Facility/Location]

Primary Surgeon: [Surgeon name and credentials]

Assistant(s): [Assistant name(s) and role(s) / None]

Anesthesia: [Anesthesia type] by [Anesthesia provider]

Laterality and Site: [Laterality and anatomic site] (Do not infer; use only explicitly documented information)

Preoperative Diagnosis

• [Diagnosis with implant-related problem, laterality, and anatomic location]
• [Additional diagnosis if applicable]

Postoperative Diagnosis

• [Updated diagnosis with laterality and anatomic location] (Update based on intraoperative findings; if infection was an indication, state whether confirmed, suspected, or not supported)
• [Additional diagnosis if applicable]

Procedure(s) Performed

• [Procedure with anatomic location and laterality] (List chronologically; include any procedures added intraoperatively)
• [Additional procedure(s) as applicable]

Indications

Implant history: [What implant(s) were placed, anatomic location, and approximate date of original surgery]

Current presentation: [Symptoms, functional impact, exam findings, and/or imaging studies describing the failure mode]

Indication(s) for surgery: [Applicable indications: pain/prominence with failed conservative treatment, infection signs, nonunion/delayed union, hardware failure/malposition] (Include only applicable indications)

Rationale: [Reasoning for removal versus retention versus exchange]

Operative Findings

• Hardware status: [Intact / broken / loose / stripped; bony overgrowth; prominence]
• Bone status: [Union status; nonunion type if present; bone loss or defect]
• Soft tissue status: [Scar tissue; tendon or retinaculum irritation; neurovascular integrity]
• Infection findings: [Purulence present / absent; sinus tract; membrane appearance] (Include only if infection was an indication or findings are present)
• Exchange assessment: [New implant stability; alignment/length/rotation confirmation] (Include only if exchange performed; state imaging confirmation only if explicitly documented)

Description of Procedure

Approach and exposure: [Patient positioning; prep and drape; incision location and length; dissection; protection of critical structures; method of implant localization; tourniquet parameters if used]

Hardware removal: [Construct(s) removed; technique; challenges encountered such as bony overgrowth or stripped fasteners; extraction tools used; any hardware intentionally retained with location and rationale]

Implant exchange: [Rationale; canal or bed preparation; new implant insertion and fixation; alignment/length/rotation assessment; imaging confirmation if documented] (Include only if exchange performed)

Debridement and irrigation: [Tissue layers debrided; irrigation type and volume; local antibiotic adjuncts] (Include only if performed)

Closure: [Hemostasis; layer-by-layer closure; drains placed with type and location; dressing; immobilization applied]

Hardware Inventory

Removed

• [Anatomic location] — [Device type] — [Manufacturer/size if known] — [Condition: intact / broken / loose] — [Removal method]
• [Additional items as applicable]

Retained

[Hardware retained with location, reason for retention, and implications for future care / None]

Implanted

• [Implant type] — [Location] — [Size] (Full identifiers per facility implant log if not available at dictation)
• [Additional implants as applicable]

(State "None" under Implanted if removal only without exchange)

Specimens and Cultures

• [Source/site] — [Type: tissue / fluid / bone / hardware] — [Destination: microbiology / pathology] — [Tests requested] — [Timing relative to antibiotics if relevant]
• [Additional specimens as applicable]

(If infection is a consideration, document that multiple deep tissue specimens were obtained. If no specimens sent, state "None.")

Estimated Blood Loss

EBL: [mL]. [Tourniquet pressure and total time if used.] (Reference anesthesia record if details captured there)

Complications

[None / Description of complication, immediate management, and follow-up plan] (This section must always be present with an explicit statement)

Disposition

[Patient condition at case end]; [Destination: PACU / ICU / ward / home]; [Neurovascular exam status of affected extremity]

Postoperative Plan

• Weight bearing: [Status and affected limb]
• Immobilization/ROM: [Splint / cast / brace and range of motion instructions]
• Wound care: [Dressing changes; showering instructions; suture/staple removal timing]
• Antibiotics: [Agent, duration; note culture-directed adjustment plan if applicable]
• DVT prophylaxis: [Agent and duration]
• Drains: [Care instructions and removal criteria] (Include only if drains placed)
• Follow-up: [Timing; planned imaging or labs]