OT notes · Orthopaedics

Hemiarthroplasty of the hip (bipolar / Austin Moore)

Usual anaesthesia
Spinal (subarachnoid block)
Position
Lateral decubitus, operated side up, pelvis held with supports (posterior approach); supine for anterolateral or anterior approach
Setting
emergency

Operative note template for hemiarthroplasty of the hip for femoral neck fracture, with a filled example for a cemented bipolar hemiarthroplasty through the posterior approach in an elderly woman 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 of the prosthesis
  • fracture of the femur during stem insertion
  • leg length difference
  • sciatic nerve injury
  • sudden fall in blood pressure or oxygen level when cement is inserted (bone cement implantation syndrome), rarely cardiac arrest
  • deep infection needing further surgery
  • deep vein thrombosis and pulmonary embolism
  • loosening, wear of the acetabulum and pain needing revision
  • high risk of death within the first year in elderly patients, from the injury itself

Pre-operative details for this operation

  1. Side and diagnosisright / left, displaced femoral neck fracture, Garden type, date of injury
  2. Reason for hemiarthroplasty rather than fixation or THRage, pre-injury walking, cognition, medical fitness
  3. Pre-op X-raysAP pelvis, AP and lateral of injured hip; templating for stem size and head size
  4. Cement risk assessmentage, heart or lung disease, diuretics, male sex; discussed with anaesthetist before surgery
  5. Anticoagulant / antiplatelet statusdrug, last dose
  6. Blood grouped and cross-matchedgroup, units reserved
  7. Implant and cement availability checkedstem sizes, head sizes, cement packets, cement gun, canal plug

Anaesthesia and position

  1. AnaesthesiaSpinalSpinal with nerve blockGeneral
  2. PositionLateral decubitusSupinepelvic supports against pubic symphysis / ASIS and sacrum, not on the femoral triangle; bony points and peroneal nerve padded
  3. ApproachPosterior (Southern / Moore / posterolateral)Anterolateral (Hardinge / Watson-Jones)Direct anterior
  4. Blood pressure monitoring at cementingArterial lineNIBP on frequent cycling
  5. TourniquetNot applicable

Operative findings

  1. Fracturesubcapital / transcervical / basicervical; comminution of posterior neck or calcar
  2. Femoral headdiameter of removed head in mm; head appearance
  3. Acetabular cartilageNormalWorn / arthritic
  4. Bone quality and canalOsteoporotic, wide canalGood boneNarrow canal
  5. Haematoma / joint fluidif old fracture or infection suspected, fluid sent

Procedure (steps)

  1. Painting and drapingantiseptic, U-drape sealing perineum, foot in stockinette
  2. Incision and fascialength, centred on greater trochanter; fascia lata divided, gluteus maximus split
  3. Short external rotators and capsulepiriformis and obturator internus tagged, divided at femoral insertion; capsule opened and kept for repair; sciatic nerve palpated and protected
  4. Head removedneck cut level above lesser trochanter (mm); head extracted with corkscrew; ligamentum teres and fragments cleared from acetabulum
  5. Head size measuredremoved head diameter; trial head size that fits the acetabulum
  6. Femoral canal preparationentry lateral in the neck toward the trochanter; box osteotome / canal finder; broach sizes; anteversion
  7. Trial reductionstem, neck length and head size; stability in flexion with internal rotation and in extension with external rotation; leg length compared
  8. Cement technique (if cemented)Plug, lavage, dry canal, gun retrogradeHand packing (finger)Uncemented press-fitanaesthetist told before cementing; plug size and depth; number and weight of cement packets; pressurisation used or avoided
  9. Response to cementingBP and SpO2 before and after cement and stem insertion; any drop, grade, treatment given
  10. Stem insertedsize, anteversion, held still till cement set; extra cement removed
  11. Head assembled and hip reducedtaper cleaned and dried, head impacted; bipolar outer diameter and inner head size; final stability and leg length
  12. Check for fracturecalcar and trochanter inspected after stem insertion; cerclage if needed

Closure, drains and dressing

  1. Capsule and short external rotatorsrepaired to trochanter through drill holes with non-absorbable suture
  2. Gluteus maximus insertion / quadratus femorisrepaired if divided
  3. DrainNoneClosed suction drain deep to fascia
  4. Fascia lataclosed with hip in slight abduction; suture material
  5. Subcutaneous tissue and skinsuture material or staples
  6. Dressing and abduction pillowpillow applied in OT
  7. Neurovascular status at enddistal pulses, capillary refill; ankle and toe dorsiflexion (sciatic / peroneal) when block allows

Specimens and implants

  1. Femoral stemdesign, cemented / uncemented, size, make, lot / batch number, sticker in case sheet
  2. Headbipolar outer diameter and inner head size with neck length, or unipolar head size; make, lot / batch, sticker
  3. Bone cementnumber and weight of packets, plain or antibiotic-loaded, make, lot / batch, sticker
  4. Canal plug / centralisersize, lot / batch, sticker
  5. Femoral headDiscarded as biomedical wasteSent for HPE (suspected pathological fracture)Kept for 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 SpO2every 15 min for the first hour then hourly; oxygen as ordered; watch for late fall in BP or SpO2
  2. Limb checkdistal pulses, ankle and toe movement, sensation; hourly for 4 hours then 4-hourly
  3. Positionhip in about 15 degrees of abduction with triangular pillow after posterior approach; pillow between knees when turning
  4. Check X-rayAP pelvis and lateral of operated hip
  5. Analgesiadrug, dose, frequency
  6. Mobilisationsit up and stand with walker from POD 1; weight bearing as tolerated if cemented
  7. Dislocation precautionsas per surgeon: avoid deep flexion with adduction and internal rotation, raised toilet seat
  8. Drainremoval time if placed
  9. Hb on POD 1and electrolytes in the elderly
  10. Suture removal and follow-upat about 2 weeks; review with X-ray 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: Mrs. P.D., 79 years, fell at home, displaced subcapital fracture of the right femoral neck (Garden IV), walks indoors with a stick, on a diuretic for hypertension.

Case details

Date: 18/06/2026. Trauma list. OT 1.

In OT 09:10. Spinal given 09:20. Skin incision 09:52. Cement inserted 10:31. Skin closed 11:05.

Surgeon: Dr A. (3rd-year resident, Orthopaedics), under direct supervision of Dr C. (consultant), scrubbed. Assistant: Dr B. (1st-year resident).

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: displaced right subcapital fracture, Garden IV, 2 days old. Age 79, walks indoors with a stick, so hemiarthroplasty chosen over fixation and over THR.

Cement risk: age, hypertension on furosemide. Discussed with Dr D. on the evening before surgery. Arterial line planned.

Aspirin stopped on admission. Hb 11.2 g/dl, K+ 3.9 mmol/l. Blood group A positive, 2 units cross-matched.

Consent: general, procedure-specific and anaesthesia consent taken in Hindi from patient and daughter. Dislocation, fracture, leg length difference and cement reaction explained.

Right hip marked. WHO checklist sign in and time out done; cement plan stated at time out. Inj cefazolin 2 g IV at 09:35, before skin incision.

Anaesthesia and position

Spinal anaesthesia. Arterial line in left radial artery. Left lateral decubitus, right side up, pelvic supports on pubic symphysis and sacrum, left peroneal area padded.

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

Procedure

Posterior (Southern) approach. 14 cm curved incision centred on the greater trochanter. Fascia lata divided, gluteus maximus split in line with fibres.

Sciatic nerve palpated and protected. Piriformis and obturator internus tagged with braided polyester No. 2 and divided at their insertion. Posterior capsule opened as a flap and tagged.

Fracture: subcapital, posterior neck comminution. Haematoma evacuated. Neck trimmed 12 mm above lesser trochanter. Head removed with corkscrew. Head diameter 45 mm. Acetabular cartilage normal. Ligamentum teres and fragments removed.

Canal opened with box osteotome and canal finder aimed laterally. Broached up to size 3 in about 15 degrees of anteversion. Bone osteoporotic with a wide canal.

Trial reduction with size 3 stem, standard neck and 45 mm bipolar trial: stable at 90 degrees flexion with 45 degrees internal rotation and in extension with external rotation. Leg lengths equal (knee levels compared).

Anaesthetist informed before cementing and acknowledged. Canal plug 14 mm placed 2 cm below planned stem tip. Canal washed with pulsatile lavage and dried. Two packets (40 g each) of plain bone cement, vacuum mixed, injected retrograde with gun and suction catheter. Only gentle pressurisation because of her risk factors.

Cemented stem size 3 inserted in 15 degrees of anteversion and held still till the cement set. Extra cement removed.

At cementing, systolic BP fell from 132 to 112 mmHg (15 percent) and SpO2 stayed 97 percent. Recovered in 2 minutes with fluid bolus. No bone cement implantation syndrome by AAGBI grading.

Taper cleaned and dried. Bipolar head 45 mm (inner head 28 mm, standard neck) impacted. Hip reduced, stable. Calcar and trochanter checked: no fracture.

Closure

Capsule and short external rotators repaired to the posterior 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 slight abduction. Subcutaneous tissue with Vicryl 2-0. Skin with staples. Sterile dressing. Abduction pillow applied in OT.

Specimens and implants

Cemented femoral stem size 3. Bipolar head 45 mm outer diameter with 28 mm standard-neck inner head. Bone cement 2 x 40 g, plain. Canal plug 14 mm.

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

Femoral head discarded as yellow category biomedical waste. No specimen. No tourniquet.

End of procedure

Estimated blood loss 350 ml (suction 200 ml + mops). No transfusion in OT.

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

No intra-operative complications apart from the brief BP fall at cementing noted above.

Right foot warm, dorsalis pedis pulse palpable, capillary refill under 2 seconds. Active ankle dorsiflexion to be checked when block wears off; handed over to recovery nurse.

Shifted to recovery. Pulse 88/min, BP 124/70 mmHg, SpO2 97 percent on room air.

Post-op orders

Pulse, BP, SpO2 every 15 min for 1 hour, then hourly for 6 hours. Oxygen by mask if SpO2 below 94 percent.

Distal pulses and ankle and toe movement hourly for 4 hours, then 4-hourly.

Abduction pillow between legs. Avoid flexion beyond 90 degrees and crossing legs.

Analgesia as per unit acute pain protocol (drug, dose and times written on the drug chart). Thromboprophylaxis as per unit protocol.

Check X-ray AP pelvis and lateral of right hip. Hb and electrolytes on POD 1.

Stand and walk with walker, full weight bearing, from POD 1 with physiotherapist.

Staples out at 2 weeks. Review with X-ray at 6 weeks.

Signature

Dr A., JR-3, Orthopaedics. Reg. no. ________. 18/06/2026, 11:20.

Must document for this operation

  • Why hemiarthroplasty was chosen over fixation or total hip replacement (THR). The choice depends on age, walking status and cognition, and is questioned if the result is poor.
  • Approach used and whether the capsule and short external rotators were repaired. Dislocation risk is higher with the posterior approach, and a surgeon reducing a dislocation needs to know the approach.
  • Cemented or uncemented, cement packets and lot number, and how the cement was delivered. Cement technique is audited after any intra-operative collapse or early loosening.
  • Blood pressure and oxygen saturation at cementing and any reaction with its grade. Bone cement implantation syndrome (BCIS) is a known cause of death on the table, and the note must show it was watched for and treated.
  • Stem size, head outer diameter, inner head size and neck length, with make and lot numbers and stickers. Needed for implant recall, for the discharge summary, and to order matching parts if the hip dislocates or needs revision.
  • Removed head diameter and state of acetabular cartilage. They justify the head size used and give a baseline if acetabular wear causes pain later.
  • Distal pulses and sciatic nerve function at the end. A foot drop found later cannot be timed unless the note records the state at the end of surgery.

Common mistakes in these notes

  • Writing 'bipolar done' with no stem size, head size or neck length.
  • Not recording that the anaesthetist was told before cementing, or leaving out the BP change at cementing.
  • Forgetting the cement lot number and sticker.
  • Not writing whether the posterior capsule and rotators were repaired.
  • Leaving out whether the removed head was sent for HPE when a pathological fracture was possible.
  • No record of foot movement or distal pulses at the end.

Indian practice and paperwork

  • Record the batch and serial number of every implant (stem, head, cement) 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 removed femoral head, if not sent for HPE, is human anatomical waste and goes in the yellow category bag. (CPCB/MoHFW guidelines under Bio-Medical Waste Management Rules 2016, yellow (a))

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, posterolateral approach, Techniques 4.5 and 4.6 (femoral component implantation, cemented), soft-tissue repair and closure, acute femoral neck fractures, postoperative management, pp. 219-235, 254-255, 328-329.
  • Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; copyright 2027, Ch 60 Fractures and dislocations of the hip: femoral neck fractures, arthroplasty, pp. 2664-2665.
  • Azar FM, Beaty JH, eds. Campbell's Core Orthopaedic Procedures. 2nd ed. Elsevier; 2024, Technique 1 Total hip arthroplasty: standard posterolateral approach (Harkess JW, Crockarell JR), exposure and removal of the femoral head, pp. 1-6.
  • Griffiths R, White SM, Moppett IK, et al. Safety guideline: reducing the risk from cemented hemiarthroplasty for hip fracture 2015 (AAGBI, BOA, BGS). Anaesthesia. 2015;70(5):623-6. Risk factors, surgeon to inform anaesthetist before cement, wash and dry canal, retrograde gun with suction catheter and plug, avoid vigorous pressurisation in high-risk patients, BCIS grades 1-3. doi.org/10.1111/anae.13036
  • 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. 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.

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