Hip Fracture Surgery Operative Report (Fixation/Hemiarthroplasty)

Date of Surgery: [Date] Start Time: [Start time] End Time: [End time]

Facility/OR: [Facility name and OR number]

Laterality: [Left / Right] (Confirmed with time-out)

Primary Surgeon: [Primary surgeon name and credentials] Assistant(s): [Assistant names and roles]

Anesthesia Type: [General / Spinal / Regional / MAC]

Preoperative Diagnosis: [Preoperative diagnosis]

Postoperative Diagnosis: [Postoperative diagnosis]

Procedure(s) Performed: [All procedures performed, including adjuncts such as cerclage, open reduction, bone grafting]

Indications and Procedure Selection

[Mechanism of injury and clinical context] (Include ground-level fall, higher-energy trauma, or pathologic concern. Note relevant timing from injury or medical optimization if applicable.)

[Fracture pattern summary] (State intracapsular femoral neck vs basicervical vs intertrochanteric vs subtrochanteric; describe displacement, stability, comminution, lateral wall integrity, and any reverse obliquity or atypical features.)

• Fracture factors: [Displacement, stability, bone quality, comminution, lateral wall integrity]
• Patient factors: [Age, pre-fracture mobility, cognitive status, pre-existing hip arthritis, functional goals]
• Procedure-choice rationale: [Why fixation vs arthroplasty was selected to optimize durability, reduce reoperation risk, and support functional recovery]

[Consent statement] (Document who consented and that risks, benefits, and alternatives—including nonoperative management and other surgical options—were discussed.)

Preoperative Preparation

• [Antibiotic prophylaxis: agent, dose, and timing relative to incision]
• [Tranexamic acid: dose and timing] (Include only if administered.)
• [Time-out completed: patient identity, procedure, and laterality confirmed]
• [Positioning: supine / lateral; fracture table / regular table; padding and supports]
• [Anesthesia alerted prior to cementation] (Include only for cemented arthroplasty.)

Operative Findings

• [Fracture pattern confirmed intraoperatively] (Include classification if used locally; otherwise use descriptive language.)
• [Bone quality assessment]
• [Associated findings: hematoma, comminution pattern, calcar integrity, lateral wall status]
• [Acetabular cartilage and femoral head condition] (Include only for arthroplasty.)
• [Intraoperative change from plan with rationale] (Include only if plan changed.)

Procedure Details

(Use concise chronological narrative. Complete common elements for all procedures, then include only the applicable procedure pathway.)

Common Elements

[Surgical approach and skin incision with key landmarks]

[Key structures protected]

[Fluoroscopy use and what was confirmed]

[Irrigation and hemostasis]

[Closure: layers closed, suture types and sizes, staples if used]

[Dressing applied]

Internal Fixation Pathway

(Include only when internal fixation was performed.)

Reduction: [Closed vs open reduction; maneuvers used; traction and rotation details] [Reduction quality statement: alignment (varus/valgus), rotation, apposition; anatomic or near-anatomic achieved]

Fixation Construct: [Device family (cannulated screws / SHS-DHS / cephalomedullary nail); key steps including entry point, guidewire placement, reaming, lag screw or blade insertion, compression if applied, and locking technique]

• Nail parameters: [Length, diameter, neck-shaft angle; proximal element type and size; distal locking configuration and screw count] (Include only for cephalomedullary nail.)
• SHS/DHS details: [Lag screw length; side plate length and holes; cortical/locking screw count] (Include only for sliding hip screw.)
• Cannulated screws: [Number, configuration, lengths, diameters; washer use if applicable] (Include only for cannulated screw fixation.)
• Adjuncts: [Cerclage, bone grafting] (Include only if used.)

Position Verification: [Quality confirmation] (Document tip-apex distance if measured; otherwise state fluoroscopy confirmed acceptable reduction and hardware position in AP and lateral views.)

Hemiarthroplasty Pathway

(Include only when hemiarthroplasty was performed.)

Exposure: [Approach: posterior / anterolateral / direct lateral / anterior]; [Femoral neck cut level]; [Head removal and disposition to pathology if sent] (For posterior approach, document capsule and external rotator repair.)

Femoral Preparation: [Canal preparation and broach sequence to final size]; [Cemented vs uncemented with rationale if nonstandard] (If cemented, note canal lavage, restrictor, cement type, and team communication.)

Trialing and Final Implantation: [Head type: unipolar / bipolar]; [Head size and neck length]; [Stability assessment through ROM]; [Leg length and offset assessment method]

Total Hip Arthroplasty Pathway

(Include only when THA was performed.)

THA Indication: [Rationale for THA over hemiarthroplasty] (Include if not addressed in Indications section.)

Acetabular Component: [Reaming strategy]; [Final cup size and fixation method]; [Liner type: standard / elevated rim / dual mobility / constrained] (Provide rationale if non-standard liner.)

Femoral Component: [Broaching sequence and final stem size]; [Cemented vs uncemented]; [Head size and neck length]; [Stability testing and leg length/offset assessment]

Hip Precautions/Stability Measures: [Approach-based precautions or implant choices addressing instability risk] (Include if applicable.)

Implants

• [Implant type, size, manufacturer/model] [Cement type if cemented, note if antibiotic-loaded]
• [Additional implants as needed]

(Full implant identifiers in implant log.)

Specimens

[None / Specimen type, destination, and indication]

Drains

[None / Type and location]

Estimated Blood Loss and Fluids

• EBL: [Estimated blood loss in mL] (Required—do not leave blank.)
• Blood products: [None / Units and type transfused]
• IV fluids: [Volume and type / See anesthesia record]
• Urine output: [Volume / See anesthesia record]

Complications

[None / Description of complication, intraoperative management, and impact on postoperative care] (Use neutral, specific language.)

Counts and Safety

[Sponge, needle, and instrument counts correct. Final fluoroscopic images obtained and reviewed.]

Disposition

[Patient condition: stable / guarded with explanation]; [Destination: PACU / ICU]; [Immediate concerns if any]; [Neurovascular status of operative extremity] (Neurovascular status optional.)

Postoperative Plan

• Weight Bearing: [WBAT / PWB / TTWB / NWB with rationale for any restriction]; [Mobilization timing] (Required—do not omit.)
• Hip Precautions: [Approach-based precautions] (Include for arthroplasty if used in practice.)
• VTE Prophylaxis: [Agent, dose, and duration per protocol]
• Antibiotics: [Duration of perioperative course]
• Pain Management: [Multimodal regimen per protocol]
• Wound Care: [Dressing type, change schedule, staple/suture removal timing]
• Imaging: [Postoperative radiograph plan]
• Follow-up: [Clinic timeframe and key needs]

Attestation

I, [Surgeon name and credentials], was present and actively participated for the key and critical portions of this procedure and was immediately available for the entirety of the case. This operative report accurately reflects the procedure performed.

Surgeon Signature: ____________________________ Date/Time: ____________________________