OT notes · Orthopaedics

Open reduction of DDH (with pelvic / femoral osteotomy)

Usual anaesthesia
General anaesthesia
Position
Supine on a radiolucent table with a small pad under the affected hip; limb draped free
Setting
elective

Operative note template for open reduction of a dislocated hip in developmental dysplasia (anterior or medial approach), with or without femoral shortening and Salter or Pemberton osteotomy, with a filled example for a walking child treated by anterior open reduction, femoral shortening and Salter innominate osteotomy.

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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

  • avascular necrosis (osteonecrosis) of the femoral head
  • redislocation or residual subluxation
  • need for further surgery for residual dysplasia
  • injury to the lateral femoral cutaneous nerve (numbness on the thigh)
  • injury to the femoral or sciatic nerve or vessels
  • limb-length difference
  • wound infection
  • cast sores and stiffness after spica
  • second operation to remove wires and plate

Pre-operative details for this operation

  1. Age, side and typeUnilateral rightUnilateral leftBilateraltypical DDH or teratologic; walking age
  2. Previous treatmentPavlik harness, closed reduction, traction, earlier surgery
  3. Radiographsacetabular index, height of the femoral head above the triradiate cartilage (to estimate shortening), false acetabulum
  4. PlanOpen reduction aloneOpen reduction + femoral shorteningOpen reduction + Salter osteotomyOpen reduction + Pemberton acetabuloplastyCombined
  5. Implants and spica readyKirschner wires, small plate or paediatric hip screw, spica frame and plaster
  6. Blood grouped and cross-matchedunits reserved

Anaesthesia and position

  1. AnaesthesiaGeneral
  2. PositionSupine with small radiolucent pad under the affected hipSupine, frog-leg (medial approach)
  3. Drapingtrunk to lower ribs and midline, whole limb free
  4. Image intensifierUsed

Operative findings

  1. Femoral headposition (false acetabulum / high in abductors), shape, cartilage
  2. Blocks to reduction foundhourglass capsule, iliopsoas, inverted limbus or labrum, hypertrophied ligamentum teres, transverse acetabular ligament, pulvinar
  3. Capsulesize of redundant capsule over false acetabulum
  4. Stability after reduction (safe zone)range in which the head stays reduced; does it dislocate with knee extension at 90 degrees hip flexion
  5. Acetabular coverage after osteotomyon image intensifier

Procedure (steps)

  1. Adductor tenotomyPercutaneousOpenNot done
  2. Approach and incisionAnterior bikini (iliofemoral) incisionMedial (Ludloff) transverse incision near groin crease
  3. Lateral femoral cutaneous nerveidentified and protected (anterior approach)
  4. Iliac apophysis split / reflected, ilium exposed subperiosteallysartorius and rectus femoris detached and tagged
  5. Iliopsoas tendonrecession tenotomy over the pelvic brim, muscle kept intact
  6. CapsulotomyT-shaped (anterior)Along femoral neck (medial)
  7. Clearing the acetabulumligamentum teres detached and followed to true acetabulum, pulvinar removed, transverse acetabular ligament divided; labrum preserved
  8. Femoral shortening and derotation (if needed)lateral incision; level; length of bone removed (cm); derotation (degrees); plate or paediatric hip screw, holes and screws
  9. Reduction and safe zoneconcentric reduction on image; safe range of flexion and abduction
  10. Pelvic osteotomySalter innominatePemberton acetabuloplastyNot doneGigli saw or osteotomes; graft source and shape; number and size of K-wires; K-wires clear of the joint on image
  11. Capsulorrhaphyredundant lateral capsule excised or lateral flap pulled medially; suture used
  12. Reattachmentrectus femoris and sartorius to origins; iliac apophysis halves sutured

Closure, drains and dressing

  1. Irrigationboth wounds
  2. DrainSuction drainNone
  3. Subcutaneous tissue and skinsuture used; subcuticular
  4. K-wire endscut within subcutaneous fat / just beyond iliac crest, at different levels
  5. Spica castOne and a half hip spicaDouble hip spicahip flexion, abduction and rotation in degrees
  6. Image after spicahead reduced on image; CT / MRI planned

Specimens and implants

  1. Kirschner wiresnumber, diameter, threaded / smooth
  2. Femoral plate and screwstype, holes, screw sizes, make, batch/lot, sticker pasted
  3. Bone graftIliac crest wedgeResected femoral segmentAllograft
  4. SpecimensNone

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. Toe circulation and spica checkcolour, capillary refill, swelling at cast edges; check regularly, most often in the first 24 hours
  2. Spica carekeep the perineal opening clean and dry to avoid soiling; watch for cast sores
  3. Drainremove at 24 to 48 hours
  4. Analgesiaweight-based doses
  5. ImagingX-ray pelvis in spica; CT or MRI to confirm reduction
  6. Hbon POD 1
  7. Follow-upspica change under GA at 5 to 6 weeks if planned; spica removal and K-wire removal at 6 to 12 weeks; plate removal later
  8. Long-termserial X-rays to skeletal maturity; yearly limb-length check

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: Baby K.R., girl, 2 years 6 months, 12 kg, walking with a limp, left hip dislocation not detected earlier. X-ray: high dislocation with false acetabulum, acetabular index 38 degrees.

Case details

Date: 20/07/2026. Elective left open reduction, femoral shortening and Salter innominate osteotomy. OT 4.

In OT 09:00. Incision 09:40. Spica completed 13:10.

Surgeon: Dr A. (consultant, paediatric orthopaedics). Assistants: Dr B. (3rd-year resident), Dr C. (2nd-year resident). Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: untreated left developmental dislocation of hip in a walking child. Femoral head about 2 cm above the triradiate cartilage on X-ray.

Hb 11.2 g/dl. Blood group O positive, 1 unit cross-matched.

Consent: general, procedure-specific and anaesthesia consent from both parents in Hindi. Risk of AVN, redislocation, further surgery and wire and plate removal explained.

Left hip marked. WHO checklist sign in and time out done. Inj cefazolin 360 mg IV (30 mg/kg) at 09:25.

Anaesthesia and position

General anaesthesia.

Supine on radiolucent table with a small pad under the left hip. Parts painted with povidone-iodine from the lower ribs to the toes and draped with the left limb free. Image intensifier from the right side.

Procedure

Percutaneous left adductor longus tenotomy.

Anterior bikini incision 1 cm below the iliac crest, centred on the ASIS. Interval between sartorius and tensor fasciae latae opened; lateral femoral cutaneous nerve seen and retracted with a Penrose drain.

Iliac apophysis split and both tables of the ilium exposed subperiosteally to the sciatic notch. Sartorius and rectus femoris detached and tagged. Iliopsoas tendon divided over the pelvic brim, muscle kept intact.

Findings: head sitting in a false acetabulum above the true acetabulum. Large redundant capsule laterally. Hypertrophied ligamentum teres, thick pulvinar, contracted transverse acetabular ligament. Labrum not inverted. Head cartilage normal.

T-shaped capsulotomy. Ligamentum teres detached from the head and followed to the true acetabulum. Pulvinar removed. Transverse acetabular ligament divided.

Head reduced with the capsule held tight: head dislocated when the knee was extended at 90 degrees hip flexion. Femoral shortening therefore done.

Straight lateral incision on the thigh. Femur exposed through vastus lateralis. Transverse mark below the lesser trochanter and longitudinal mark for rotation. 4-hole 3.5 mm one-third tubular plate templated with two proximal screws and removed. Transverse osteotomy below the lesser trochanter. Head reduced; 20 degrees derotation needed. Second cut removed a 1.5 cm segment. Femur fixed with the plate and 4 screws. Reduction and plate position checked on image.

Salter osteotomy: Gigli saw passed through the sciatic notch subperiosteally with Hohmann retractors protecting the notch. Straight cut from the notch to just above the AIIS. Wedge graft shaped from the resected femoral segment. Distal fragment pulled forward, down and out with the limb in figure-of-four, osteotomy kept closed posteriorly. Graft inserted. Two 2.0 mm threaded K-wires passed from the upper ilium through the graft into the distal fragment. Image: wires clear of the joint, head concentric, good anterolateral cover.

Capsulorrhaphy: redundant lateral capsule excised and the lateral flap pulled medially and sutured with 0 braided polyester. Hip stable in the safe zone.

Rectus femoris and sartorius sutured to their origins. Iliac apophysis halves sutured with polyglactin 910 (Vicryl) 0 interrupted.

Closure

Both wounds irrigated with normal saline. Suction drain in the thigh wound.

K-wires cut 1 cm apart in length, ends in the subcutaneous fat. Subcutaneous tissue with Vicryl 2-0, skin with subcuticular poliglecaprone (Monocryl) 3-0.

One and a half hip spica applied with the hip in neutral rotation and slight flexion and abduction. Image in spica: head reduced. Toes pink.

Specimens and implants

4-hole 3.5 mm one-third tubular plate with four 3.5 mm cortical screws; two 2.0 mm threaded K-wires. Make and batch recorded; stickers pasted.

Graft from the resected femoral segment. No specimen sent.

End of procedure

Estimated blood loss 150 ml. No transfusion.

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

No intra-operative complications.

Shifted to recovery in stable condition. Pulse 118/min, SpO2 99 percent on room air.

Post-op orders

Toe colour, capillary refill and cast edges checked regularly, more often in the first 24 hours.

Keep the perineal window clean and dry to avoid soiling of the cast.

Drain removal at 24 to 48 hours. Hb on POD 1.

X-ray pelvis in spica on POD 1; CT pelvis limited cuts to confirm reduction.

Review at 2 weeks. Spica and K-wire removal under GA at 8 to 12 weeks after X-ray. Plate removal later.

Signature

Dr B., JR-3, Orthopaedics, for Dr A. Reg. no. ________. 20/07/2026, 13:30.

Must document for this operation

  • Each block to reduction found and what was done to it. If the hip redislocates, the revising surgeon needs to know which structures were already released.
  • Why femoral shortening or a pelvic osteotomy was added, with the stability test result. It shows the decision was made on findings, and it explains the extra wound and implants to the parents.
  • Length of femur removed and degrees of derotation. Needed for later limb-length follow-up and for any repeat osteotomy.
  • Safe zone and the spica position in degrees. Extreme positions raise the risk of avascular necrosis, and the next cast change is done in the same position.
  • Number, size and position of K-wires and the plate, with stickers. All of these must be removed later, and the removal surgeon plans from this note.
  • Lateral femoral cutaneous nerve seen and protected. Thigh numbness after surgery is a known risk, and the note shows the nerve was guarded.

Common mistakes in these notes

  • Writing 'open reduction done' without the approach or the blocks removed.
  • Leaving out the length of femoral shortening and the derotation angle.
  • Not writing the spica position in degrees.
  • No image confirmation of concentric reduction recorded.
  • Weight not written, so the antibiotic and fluid doses in the note cannot be checked.

Indian practice and paperwork

  • Record the batch and serial number of the plate and screws 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))
  • Consent must explain the procedure, risks, benefits, alternatives and who will operate, in a language the parents understand, and be taken by the person doing the procedure. (NABH 5th ed., PRE.4(c) and (e))

Sources

  • Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; copyright 2027, Ch 32, Congenital and developmental abnormalities of the hip and pelvis: spica cast (Technique 32.2), anterior and medial open reduction (32.3, 32.4), concomitant osteotomy, primary femoral shortening (32.6), Salter innominate osteotomy (32.8), Pemberton acetabuloplasty (32.9), pp. 1139-1155.
  • Saghieh S, et al., eds. Operative Dictations in Orthopedic Surgery. Springer; 2013, Ch 3, Open reduction of DDH, medial approach (Khoury JG); Ch 4, Salter innominate osteotomy; Ch 5, Pemberton osteotomy (Weinstein SL), pp. 13-21.
  • 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 paediatric dose 30 mg/kg, not to exceed the adult dose; within 60 min before incision; recommended for internal fixation devices. 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

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