OT notes · Orthopaedics

Hip disarticulation

Usual anaesthesia
General anaesthesia (regional block may be added for pain relief if the patient is stable)
Position
Lateral decubitus (Boyd), with the whole limb draped free so it can be moved
Setting
emergency

Operative note template for hip disarticulation by the Boyd anterior racquet method or a long posterior (gluteal) flap, with a filled example for an emergency Boyd disarticulation for a non-salvageable crushed lower limb after a road traffic accident.

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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

  • death (reported mortality 0% to 44%)
  • heavy bleeding and blood transfusion
  • flap necrosis or wound breakdown, may need further surgery
  • wound infection
  • phantom limb sensation and pain, stump pain, muscle spasms
  • deep vein thrombosis and pulmonary embolism
  • walking with a prosthesis needs much more energy; many use a wheelchair
  • need for a higher amputation (hemipelvectomy) if margins or tissues are not adequate

Pre-operative details for this operation

  1. IndicationNon-salvageable traumaSevere / life-threatening infectionArterial insufficiencyBone or soft-tissue sarcoma of femur / thighInfected hip prosthesisMassive decubitus ulcerCongenital limb deficiencywhy a lower level is not possible; tumour: biopsy result and imaging extent
  2. Second opinion / senior decisionname of consultant who took the decision; limb salvage considered
  3. Haemodynamic status and resuscitationpulse, BP, fluids and blood given before OT
  4. Blood arrangedgroup and number of units cross-matched
  5. Skin of proposed flapsviability and contamination of gluteal and anterior skin
  6. Tetanus prophylaxis and antibioticsfor trauma or infection: what was given and when
  7. Comorbiditiesdiabetes, vascular disease, renal function
  8. Relatives informed; disposal of the limb discussedHPE / to relatives on request / biomedical waste

Anaesthesia and position

  1. AnaesthesiaGeneralGeneral with epiduralinvasive lines, number of IV lines
  2. PositionLateral decubitusOther (state)
  3. Limb draped freeYes
  4. Urinary catheterInsertedAlready in situ

Operative findings

  1. Extent of injury / infection / tumourhighest level of damaged or infected muscle; bone involvement
  2. Femoral vesselsintact / thrombosed / torn; level
  3. Muscle viability at flap levelcolour, contraction, bleeding; gas or pus
  4. Hip jointclean / pus / prosthesis
  5. Flapsreach without tension; blood supply

Procedure (steps)

  1. IncisionAnterior racquet (Boyd)Long posterior / posteromedial gluteal flap (Slocum)Non-standard flaplandmarks: ASIS, 5 cm below adductor origin, 5 cm below ischial tuberosity, 8 cm below greater trochanter base
  2. Femoral vesselsartery and vein isolated, doubly ligated (suture material), divided; which first
  3. Femoral nerveligated and divided proximally
  4. Anterior musclessartorius from ASIS, rectus femoris from AIIS, pectineus 0.6 cm from pubis, iliopsoas at lesser trochanter
  5. Medial muscles and obturator vesselsadductors and gracilis off pubis, ischial part of adductor magnus; obturator branches ligated; obturator externus cut at femur, not at pelvis
  6. Lateral and posterior musclesgluteus medius and minimus off greater trochanter; fascia lata and gluteus maximus insertion divided and reflected
  7. Sciatic nervetraced up, ligated and divided high
  8. Short external rotators and hamstringsrotators at femur; hamstrings off ischial tuberosity
  9. Disarticulationcapsule and ligamentum teres divided; limb removed; time
  10. Haemostasis and irrigationvolume of saline; bleeding points
  11. Flap myoplastygluteal muscles sutured to pectineus and adductor origins / fascia lata to inguinal ligament; done at primary closure, or at delayed closure if the wound is left open

Closure, drains and dressing

  1. Wound managementPrimary closure (clean, healthy flaps)Left open with negative-pressure (vacuum) dressing, relook debridement at 48 hours, delayed closure (gross contamination, severe trauma or infection)reason for the choice
  2. DrainSuction drain in the lower part of the wound (primary closure)None (wound left open)
  3. Fasciasuture material
  4. Skininterrupted non-absorbable, tension-free, if closed
  5. DressingBulky compressiveNegative-pressure dressing, pressure setting

Specimens and implants

  1. LimbSent for HPE (tumour)Handed to relatives on written requestDisposed as human anatomical waste
  2. Tissue / pus for cultureSentNot sent
  3. Margins marked for pathologist (tumour)sutures / clips at proximal margin

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. Level of careICU / HDU / ward, reason
  2. Vitals and urine outputfrequency; targets
  3. Drain and wound soakagehourly for first 6 hours; report heavy bleeding; vacuum dressing seal and canister output if wound left open
  4. Blood testsHb, electrolytes, renal function, repeat as needed
  5. Antibioticsdrug, dose, duration; change as per culture
  6. Analgesiadrug, dose, route; epidural or nerve catheter if placed
  7. Thromboprophylaxisas per unit protocol
  8. Position and pressure careturning schedule; protect the flap and opposite heel
  9. Rehabilitationphysiotherapy, wheelchair, early referral to prosthetist; counselling
  10. Relook and closure planif left open: date of relook debridement (48-hour intervals) and planned delayed closure
  11. HPE / culture follow-upwho will check the report

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: Mr. B.K., 34 years, truck driver, brought 3 hours after a road traffic accident with a crushed left lower limb from the mid-thigh down: comminuted femoral shaft fracture, torn superficial femoral vessels, extensive muscle loss and gross contamination. Limb non-viable. Gluteal and groin skin intact.

Case details

Date: 26/11/2026. Emergency. Main OT 1.

In OT 23:10. GA induced 23:20. Incision 23:45. Limb removed 01:05. Dressing completed 01:40.

Surgeon: Dr C. (Consultant, Orthopaedics). Assistants: Dr A. (3rd-year resident), Dr B. (2nd-year resident).

Anaesthetists: Dr D. and Dr F. Scrub nurse: Sr E.

Indication and pre-op

Indication: non-salvageable crushed left lower limb with injury extending to the proximal thigh, so an above-knee amputation would not leave a usable stump. Decision by Dr C. with second consultant Dr G. at 22:30; both signed.

Arrival: pulse 128/min, BP 88/56 mmHg. Resuscitated with 2 L crystalloid and 2 units PRBC. Pre-op pulse 104/min, BP 106/68 mmHg. Hb 8.4 g/dl.

Blood group O positive. 4 units PRBC and 4 units FFP cross-matched.

Tetanus prophylaxis given in casualty. Antibiotic for grade III open injury with crush started in casualty at 21:00 as per unit protocol.

Consent: written consent for hip disarticulation and possible hemipelvectomy taken from patient and wife in Hindi. Risks including death, bleeding, flap failure, phantom pain and prosthesis difficulty explained. Wife asked for the limb to be disposed by the hospital.

WHO checklist sign in and time out done. Left side marked.

Anaesthesia and position

General anaesthesia. Two large-bore IV lines, arterial line, urinary catheter. Right lateral decubitus position. Whole left limb and hemipelvis painted with povidone-iodine and draped, limb free.

Findings

Crush with dead, contaminated muscle up to 12 cm below the inguinal ligament anteriorly. Superficial femoral artery and vein torn and thrombosed. Common femoral vessels intact.

Gluteal muscles healthy, bleeding and contracting. Hip joint clean.

Procedure

Anterior racquet incision (Boyd) from the ASIS parallel to the inguinal ligament to the medial thigh 5 cm below the adductor origin, around the back 5 cm below the ischial tuberosity, and laterally 8 cm below the greater trochanter base, back to the ASIS.

Common femoral artery and vein isolated, doubly ligated and divided. Femoral nerve ligated and divided.

Sartorius detached from the ASIS and rectus femoris from the AIIS and reflected down. Pectineus divided 0.6 cm from the pubis. Thigh externally rotated, iliopsoas divided at the lesser trochanter.

Adductors and gracilis detached from the pubis, ischial part of adductor magnus divided. Obturator artery branches clamped, ligated and divided between pectineus and obturator externus.

Thigh internally rotated, gluteus medius and minimus detached from the greater trochanter. Fascia lata and lower gluteus maximus divided in line with the incision, gluteus maximus tendon released from the linea aspera and reflected up.

Sciatic nerve ligated and divided.

Short external rotators divided at the femur (obturator externus at its femoral insertion). Hamstrings detached from the ischial tuberosity.

Capsule and ligamentum teres divided. Limb removed at 01:05.

Wound irrigated with 3 L normal saline. Haemostasis secured.

Gluteal flap healthy and bleeding. Not sutured at this sitting because of gross contamination of the injury; flap to be brought forward and gluteal muscle sutured to the pectineus and adductor origins at delayed closure.

Closure

Wound left open (grossly contaminated crush injury). Flaps loosely approximated, no skin sutures. Negative-pressure (vacuum) dressing applied; pressure setting as per unit protocol (write the setting). Relook debridement planned at 48 hours, with delayed closure when the wound is clean.

Specimens and implants

Left lower limb disposed by the hospital as human anatomical waste, as requested by the wife. Muscle tissue sent for culture. No implants.

End of procedure

Estimated blood loss 1,500 ml. 2 units PRBC and 2 units FFP transfused in OT.

Mop, needle and instrument count correct.

No intra-operative cardiac arrest. Hypotension to 80/50 mmHg during femoral vessel dissection, corrected with fluids and blood.

Shifted to surgical ICU, intubated. Pulse 98/min, BP 112/70 mmHg on no vasopressor.

Post-op orders

Surgical ICU. Pulse, BP and urine output hourly. Vacuum dressing seal and canister output hourly for 6 hours; report any fresh blood in the canister to the resident on call.

Hb, electrolytes and creatinine at 06:00.

Antibiotics, analgesia and thromboprophylaxis as per ICU and unit protocol.

Culture report to be followed by the admitting unit. Relook debridement and change of vacuum dressing in OT on 28/11/2026 (48 hours); consent and blood to be arranged.

Pressure care of the flap and the right heel. Physiotherapy and counselling once extubated. Prosthetist referral before discharge.

Signature

Dr A., JR-3, Orthopaedics, for Dr C. Reg. no. ________. 27/11/2026, 02:00.

Must document for this operation

  • Why a lower level of amputation or limb salvage was not possible, and who took the decision. Loss of a whole limb is scrutinised in audits and in court, and the reasoning must be on record.
  • How the femoral and obturator vessels were controlled. Bleeding is the main early danger, and a surgeon re-exploring needs to know what was ligated and where.
  • Which nerves were ligated and at what level. Stump and phantom pain are common, and the note helps plan any later neuroma surgery.
  • Type of flap and its viability at closure. Flap necrosis is a common complication, and the note shows the flap was healthy when closed.
  • What happened to the amputated limb. Relatives may ask for the limb, and disposal must follow biomedical waste rules and be recorded.
  • Estimated blood loss, blood products given and haemodynamic events. These guide ICU care in the first 24 hours.
  • Names of all anaesthetists and surgeons present. An Indian consumer forum held a hospital negligent when the operation note left out an anaesthetist's name.

Common mistakes in these notes

  • Writing 'hip disarticulation done' with no flap type and no statement of how vessels were controlled.
  • Not recording the decision-maker and second opinion for an emergency limb loss.
  • Leaving out the disposal of the limb.
  • Not writing EBL and transfusions in a high-blood-loss operation.
  • Not recording hypotension or other intra-operative events.

Indian practice and paperwork

  • The amputated limb is human anatomical waste (yellow category) and goes to the common biomedical waste treatment facility unless sent for HPE. Write what was done with it. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)
  • Name every anaesthetist in the note. A hospital was held negligent when the operation note did not name the anaesthetist though two had given anaesthesia. (Thomas J. Indian J Urol 2009;25(3):384-8)
  • Tetanus prophylaxis should be given when indicated; record it for trauma cases. (NHSRC NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, ME E15.2)
  • Consent must explain the procedure, risks, benefits, alternatives and who will operate, in a language the patient understands. If the operation might extend to a hemipelvectomy, include it in the consent; an extra procedure without consent is defensible only when needed to save life or health. (NABH 5th ed. (2020), PRE.4(c); Samira Kohli v. Dr Prabha Manchanda, (2008) 2 SCC 1)

Sources

  • Azar FM, Sawyer JR, et al., eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier, Ch 19, Amputations of the hip and pelvis (Cleveland KB): disarticulation of the hip, Techniques 19.1 (Boyd) and 19.2 (Slocum), pp. 718-720.
  • Karakousis CP. Atlas of Operative Procedures in Surgical Oncology. Springer; 2015, Ch 53, Hip disarticulation, pp. 355-360.
  • Campbell's Operative Orthopaedics 15e, Ch 70, Table 70.2 (pdf 4002): antibiotic choice for Gustilo grade III and crush injuries (ceftriaxone; piperacillin-tazobactam for crush / farm contamination), 24 h after debridement and wound cover.

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

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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