Total Hip Arthroplasty Operative Report

Patient: [Full name and identifiers]

DOB: [Date of birth]

Date of Surgery: [Date]

Facility: [Facility name]

Procedure: [Right / Left / Bilateral] Total Hip Arthroplasty [with qualifiers if applicable]

Surgeon: [Surgeon name, credentials]

Assistant(s): [Assistant name(s) and role(s)] (Omit line if none.)

Anesthesia: [General / Spinal / Epidural / Combined / MAC] by [Anesthesia provider name, credentials]

Diagnoses and Indications

• Preoperative Diagnosis: [Diagnosis with laterality]
• Postoperative Diagnosis: [Diagnosis with laterality] (Note intraoperative changes from preoperative diagnosis if any; otherwise same as above.)

[Indication statement summarizing functional limitation and failure of conservative management in 1–2 sentences]

Procedures Performed

• [Right / Left / Bilateral] Total Hip Arthroplasty
• [Additional procedures with laterality] (Include hardware removal, bone grafting, abductor repair, osteotomy, cerclage, navigation/robotics if used. If none, state: Additional procedures: None.)

Perioperative Verification and Prophylaxis

[Informed consent obtained. Surgical time-out performed confirming correct patient, procedure, and laterality. Prophylactic antibiotic administered: agent, dose, and timing; document alternative if allergy.] (Keep to 2–3 concise sentences.)

Positioning and Approach

[Patient positioning: lateral decubitus / supine] on [table type] with [padding and protective measures]. [Surgical approach: posterior / direct anterior / anterolateral / lateral]. [Key exposure steps relevant to future care.] (For posterior approach, document short external rotator and capsular management. For anterior approach, document intermuscular interval and any releases performed. Note relevant anatomic factors such as dysplasia, contracture, osteophytes, or bone quality affecting exposure.)

Operative Findings

• [Femoral head and neck pathology observed]
• [Acetabular cartilage, bone quality, and defects]
• [Unexpected findings] (e.g., purulence, occult fracture, soft tissue abnormality. Omit unassessed elements rather than implying normal.)

Acetabular Preparation and Implantation

[Acetabular exposure description.] [Sequential reaming performed from starting size to final size.] (Include sizes if available.) [Defect management if any.] [Cup implantation: press-fit / cemented] with [orientation details]. (If navigation/robotics used, document measured inclination and anteversion. If freehand, state target orientation and assessment method.) [Screw fixation: number, location, and rationale; or state No screws used.] [Liner inserted: type and size; locking mechanism engagement confirmed.]

Femoral Preparation and Implantation

[Femoral neck osteotomy level relative to templating or anatomic landmarks.] [Canal preparation: entry point, sequential broaching to final size.] [Stem fixation: press-fit / cemented]. (If cemented, describe canal preparation, cement type, pressurization, and mantle quality.) [Stem version strategy and confirmation method.] [Femoral head selection: diameter, material, neck length.]

Trial Reduction, Stability, and Leg Length Assessment

• Trial Components: [Trial shell/liner, trial stem/broach size, trial head size and length] (Include if different from final implants.)
• Leg Length Assessment Method: [Templating reference / medial malleoli comparison / intraoperative measurement device / navigation / fluoroscopy]
• Leg Length Result: [Equal to contralateral / shortened by __ mm / lengthened by __ mm] (Quantify if measured.)
• Offset Restoration: [Restored / decreased / increased relative to contralateral] (State basis of assessment.)
• Stability Testing: [Maneuvers performed and results] (For posterior approach: flexion/adduction/internal rotation; for anterior approach: extension/external rotation. Include impingement assessment.)
• Intraoperative Adjustments: [Component changes made based on trialing with rationale] (e.g., head length change, liner constraint, component repositioning. State None if no changes made.)

(If assessment was limited by patient factors, document limitation and alternative assessment method used.)

Final Implants

(Populate from implant stickers/record; never infer values.)

• Acetabular Shell: [Manufacturer, model, size, fixation]
• Screws: [Number and lengths] (or None)
• Liner: [Type/material, size, bearing surface, constraint level if applicable]
• Femoral Stem: [Manufacturer, model, size, offset, fixation]
• Femoral Head: [Material, diameter, neck length]
• Additional: [Cement type, bone graft products, cables/cerclage/augments] (Omit line if none.)

UDI/serial numbers captured in implant log and linked to patient record.

Closure

[Irrigation solution and volume; adjuncts such as dilute betadine or topical tranexamic acid if used.] [Hemostatic agents if applied.] [Drains: type and location, or No drains placed.] [Layered closure: capsule and soft tissue repair with approach-specific details, fascia, subcutaneous tissue, and skin closure method.] [Dressing applied.]

Intraoperative Data

• Estimated Blood Loss: [___ mL]
• Specimens: [Specimens sent with destination] (or None)
• Cultures: [Site and number] (Omit line if none obtained.)
• Counts: [Sponge, needle, and instrument counts correct.] (If discrepancy, document reconciliation.)

Complications

[Complication description with consequence and management] (or None if explicitly confirmed by surgeon. Do not default to None—must be actively verified.)

Disposition

• Patient Condition: [Stable / Unstable] [with any immediate concerns]
• Disposition: [PACU / ICU / Other]
• Postoperative Imaging: [AP pelvis in PACU / Other imaging plan] (Omit if none planned.)

Postoperative Plan

• Weight Bearing: [WBAT / Partial weight bearing (__%) / Toe-touch weight bearing / Non-weight bearing] (State rationale if restricted.)
• Hip Precautions: [Posterior precautions / Anterior precautions / No formal hip precautions per surgeon protocol] for [duration]. (Include abductor precautions if repair performed.)
• DVT Prophylaxis: [Mechanical prophylaxis: SCDs/IPC] plus [chemoprophylaxis agent, dose, start timing, and duration]. (Note modifications for VTE history or bleeding risk.)
• Antibiotics: [Discontinue per standard protocol] (or Extended course: indication and duration.)
• Activity/Rehabilitation: [Mobilization timing, specific restrictions, brace use if applicable]
• Wound Care: [Dressing management, drain care if present, suture/staple removal timeline]
• Follow-up: [Clinic appointment timeframe; planned labs or imaging]