OT notes · Orthopaedics

ORIF of pelvis and acetabulum

Usual anaesthesia
General anaesthesia
Position
Acetabulum posterior wall: prone on a fracture table with distal femoral traction, or lateral on a radiolucent table; hip extended and knee flexed. Symphysis: supine on a radiolucent flat-top table, legs together
Setting
urgent

Operative note template for open reduction and internal fixation of the pelvic ring (symphysis plating through a Pfannenstiel approach) or the acetabulum (posterior wall through the Kocher-Langenbeck approach), with a filled example for a posterior wall acetabular fracture after a reduced posterior hip dislocation.

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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

  • sciatic nerve injury (foot drop)
  • heavy bleeding and blood transfusion
  • post-traumatic arthritis of the hip needing later hip replacement
  • avascular necrosis of the femoral head
  • heterotopic ossification and stiffness
  • infection
  • deep vein thrombosis and pulmonary embolism
  • loss of reduction or implant failure
  • bladder, urethral or vessel injury (symphysis)
  • screw in the hip joint needing re-operation

Pre-operative details for this operation

  1. Injury and fracture typeAcetabulum: posterior wallAcetabulum: posterior wall with dislocationAcetabulum: other pattern (write Letournel type)Pelvic ring: APC II (symphysis)Pelvic ring: APC III / vertically unstabledate and mechanism of injury, days since injury
  2. Initial managementresuscitation, units transfused, sheet or binder, angioembolisation, date and time of closed reduction of hip, skeletal traction
  3. Nerve status before surgerysciatic nerve (peroneal and tibial divisions), L4 and L5 roots; write motor power and sensation
  4. Urological assessment (pelvic ring)blood at meatus, retrograde urethrogram / CT cystogram result, catheter
  5. Soft tissuesNormalMorel-Lavallee lesionOpen wound / perineal wound
  6. Imaging reviewedAP, Judet (obturator and iliac oblique), inlet and outlet views; CT: fragment size, marginal impaction, intra-articular fragments, transverse line
  7. Blood and implantsunits cross-matched; pelvic reconstruction plates, 3.5 mm and 2.7 mm screws, pelvic clamps, C-arm

Anaesthesia and position

  1. AnaesthesiaGeneral
  2. PositionProne on fracture table, distal femoral tractionLateral on radiolucent table, limb freeSupine on radiolucent flat-top tablehip extended and knee flexed at least 80 degrees throughout (posterior approach); pressure points padded
  3. Urinary catheterFoley in placeSuprapubic catheter
  4. Mechanical DVT prophylaxiscompression devices on both legs
  5. C-arm views checked before drapingAP, obturator oblique, iliac oblique / inlet and outlet

Operative findings

  1. Sciatic nerveintact / contused / lacerated
  2. Short external rotatorsintact / avulsed
  3. Fracture fragmentssize and number of wall fragments, capsule and labrum attachment, marginal impaction, intra-articular fragments removed
  4. Femoral headcartilage damage, head fracture
  5. Symphysis (ring)diastasis, rectus avulsion, bladder and bladder neck seen
  6. Reduction achievedanatomic / step-off in mm; retroacetabular surface smooth

Procedure (steps)

  1. IncisionKocher-LangenbeckPfannenstiel, 2 cm above symphysis
  2. Superficial dissectionfascia lata divided, gluteus maximus split up to the first nerve branch / linea alba split, rectus not detached
  3. Sciatic nerve identified and protectedpiriformis and obturator internus tagged and released; retractor under obturator internus in the notch
  4. Bladder and corona mortis protected (symphysis)malleable retractor in space of Retzius; corona mortis about 6 cm lateral
  5. Fracture exposed and debridedhaematoma removed, wall fragment hinged out on capsule, joint inspected and irrigated
  6. Marginal impaction elevatedosteotome under impacted segment, reduced to femoral head, void filled (autograft / allograft / calcium sulfate)
  7. Reductionball spike pusher / Weber clamp / Jungbluth clamp / C-clamp
  8. Provisional fixationK-wires or 2.7 / 3.5 mm lag screws; spring plate for small fragments
  9. Definitive plateposterior wall: underbent 3.5 mm pelvic reconstruction plate at the wall edge, holes and screws; symphysis: 6-hole curved reconstruction or precontoured plate (not a 2-hole plate)
  10. Check for medial wall kick-upextra lag screw or spring plate if needed
  11. Final C-armjoint congruent; all screws out of the joint on obturator and iliac oblique views / symphysis reduced on AP, inlet and outlet

Closure, drains and dressing

  1. Irrigation and final nerve checksciatic nerve seen intact at the end
  2. Drainalong the posterior wall / in space of Retzius
  3. Muscle repairpiriformis and short rotators to gluteus medius tendon or trochanter; gluteus maximus tendon if released; dead muscle debrided / rectus fascia
  4. Fascia lataclosed watertight
  5. Subcutaneous tissue and skinlayered closure, suture or staples
  6. Post-op X-ray before extubationAP pelvis

Specimens and implants

  1. Platestype, holes, number, make, batch/lot, sticker pasted
  2. Screwsnumber, diameter, lag / cortical / locking
  3. Bone graft or substitutetype and amount, batch
  4. SpecimensNoneLoose fragments removed and discarded

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. Nerve checksankle and toe dorsiflexion and plantarflexion, foot sensation; check regularly and compare with the pre-op record
  2. Drainkeep till output is less than 30 ml in 24 hours
  3. DVT prophylaxismechanical plus chemical; drug, dose, duration
  4. Heterotopic ossification prophylaxisindomethacin 25 mg orally three times a day if no contraindication (posterior approach)
  5. Hip precautionsno active hip motion; passive motion only; flexion limit from surgery
  6. Weight bearingacetabulum: foot-flat for 3 months; symphysis alone: partial for about 8 weeks (12 weeks if posterior fixation)
  7. Catheterremoval plan; urology review if injury
  8. Hb and X-raysHb on POD 1; AP and Judet views / AP, inlet and outlet on POD 1; CT if joint congruence is uncertain
  9. Follow-upX-rays at 6 and 12 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: Mr. V.S., 28 years, car passenger, dashboard injury 4 days ago. Right posterior hip dislocation reduced under GA on the day of injury. CT: posterior wall fracture involving about 45 percent of the wall with marginal impaction and one small intra-articular fragment. Hip unstable on fluoroscopic stress examination. Sciatic nerve function normal.

Case details

Date: 22/06/2026. Urgent ORIF right acetabulum, posterior wall. OT 1.

Injury 18/06/2026. Closed reduction of right hip under GA 18/06/2026 at 23:30, distal femoral traction applied.

In OT 09:00. Incision 10:05. Closure completed 12:50.

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

Indication and pre-op

Indication: displaced posterior wall fracture with marginal impaction and an intra-articular fragment; hip unstable on stress examination.

Pre-op nerve status: right EHL, ankle dorsiflexion and plantarflexion power 5/5, foot sensation normal.

No Morel-Lavallee lesion. Hb 11.8 g/dl. Blood group A positive, 2 units cross-matched.

Consent: general, procedure-specific, blood transfusion and anaesthesia consent in Hindi from patient, brother present. Sciatic nerve injury, arthritis, AVN, heterotopic bone and blood transfusion explained.

Right side marked. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 09:45.

Anaesthesia and position

General anaesthesia. Foley catheter in situ. Compression devices on both legs.

Left lateral on radiolucent table with beanbag and gel pad, axillary roll, left peroneal nerve padded. Right limb draped free, hip kept extended and knee flexed throughout.

C-arm AP, obturator oblique and iliac oblique views confirmed before draping. Parts painted with povidone-iodine and draped.

Procedure

Kocher-Langenbeck incision: distal limb along the femur from the tip of the greater trochanter, proximal limb towards the PSIS. Fascia lata divided in line with the femur. Gluteus maximus split bluntly up to the first nerve branch.

Piriformis and obturator internus with gemelli tagged and released from the femur. Sciatic nerve seen lying on the short rotators, intact. Retractor placed in the lesser sciatic notch under obturator internus to protect the nerve.

Findings: posterior wall single large fragment attached to capsule, 3 cm by 2 cm, with marginal impaction posterosuperiorly. One 5 mm osteochondral fragment in the joint. Femoral head cartilage with a small scuff, no fracture. Posterior column intact, no transverse line.

Wall fragment hinged out on its capsule. Joint irrigated and loose fragment removed with traction on the limb.

Impacted segment elevated with an osteotome onto the femoral head and the void filled with cancellous allograft chips.

Wall fragment reduced with a ball spike pusher. Retroacetabular surface smooth, no step. Two 2.7 mm lag screws for provisional fixation.

8-hole 3.5 mm pelvic reconstruction plate, slightly underbent, placed at the edge of the wall from the ischium to above the joint, clear of the labrum. Screws in holes 2, 7, 8, 6 and 1. No medial wall kick-up.

Final C-arm: joint congruent, all screws out of the joint on obturator oblique and iliac oblique views.

Closure

Wound irrigated. Sciatic nerve checked again, intact. Suction drain along the posterior wall, brought out through a long track.

Piriformis and short rotators sutured to the gluteus medius tendon. Fascia lata closed watertight. Layered subcutaneous closure. Skin closed with staples.

AP pelvis in OT before extubation: hip reduced, fixation satisfactory.

Specimens and implants

One 8-hole 3.5 mm pelvic reconstruction plate with five 3.5 mm cortical screws; two 2.7 mm lag screws. Cancellous allograft chips. Make, batch and lot recorded; stickers pasted.

Loose osteochondral fragment discarded. No specimen sent.

End of procedure

Estimated blood loss 700 ml. 1 unit PRBC transfused from 12:15, no reaction.

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

No intra-operative complications.

Shifted to ICU for overnight observation in stable condition. Pulse 96/min, BP 118/70 mmHg. Right foot movements present after extubation.

Post-op orders

Right ankle and toe movements and foot sensation checked regularly and compared with the pre-op record.

Drain output charting; remove when less than 30 ml in 24 hours.

Compression devices on both legs. Chemical DVT prophylaxis as per unit protocol when there is no bleeding concern.

Tab indomethacin 25 mg three times a day if no contraindication.

No active hip motion. Passive motion only. Out of bed POD 1 with walker, foot-flat weight bearing on the right for 3 months.

Hb on POD 1. AP pelvis and Judet views on POD 1. Follow-up X-rays at 6 and 12 weeks.

Signature

Dr B., JR-3, Orthopaedics, for Dr A. Reg. no. ________. 22/06/2026, 13:10.

Must document for this operation

  • Sciatic nerve function before surgery and the nerve seen intact at the end. Nerve palsy after acetabular surgery is a common complaint, and the record must show whether it was present before the operation.
  • Date of injury and date of hip reduction. Operating more than about 3 weeks after injury lowers the chance of an anatomic reduction, so the timing must be on record.
  • Marginal impaction, loose fragments and how each was dealt with. A retained fragment or unreduced impaction leads to early arthritis, and the next surgeon needs to know what was done.
  • Final image check that no screw is in the joint, with the views used. A screw in the joint destroys cartilage, and this is the main medicolegal question after acetabular fixation.
  • Plate position, screws and graft with stickers. A later hip replacement or removal needs to plan around this hardware.
  • Blood loss and transfusion. Pelvic surgery can bleed heavily, and the post-op team monitors Hb against this figure.

Common mistakes in these notes

  • No pre-op sciatic nerve examination written.
  • Writing 'ORIF acetabulum done' without the fracture type, approach or plate position.
  • Not stating which C-arm views confirmed screws out of the joint.
  • Leaving out the weight-bearing restriction and hip precautions.
  • For the pelvic ring: not recording the urethral and bladder status.

Indian practice and paperwork

  • Record the batch and serial number of plates 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 before transfusion of blood and blood components is a separate NABH requirement, apart from the surgical and anaesthesia consent. (NABH 5th ed., PRE.2(g))
  • In an audit of 153 orthopaedic op notes at a Mumbai hospital, estimated blood loss was recorded in only 59.5 percent and closure details in 17 percent. (Tuteja S et al., Indian J Orthop 2022;56(12):2223-2227)

Sources

  • Wiesel SW, Albert TJ, eds-in-chief. Operative Techniques in Orthopaedic Surgery. 3rd ed. Vol 1. Wolters Kluwer, Pelvis and acetabulum section, Ch 4, Open reduction and internal fixation of the posterior wall of the acetabulum (Siegel J, Templeman DC), e-book PDF pp. 1040-1057.
  • Tornetta P III, ed; Wiesel SW, editor-in-chief. Operative Techniques in Orthopaedic Trauma Surgery. 2nd ed. Wolters Kluwer, Ch 34, Open reduction and internal fixation of the symphysis (Kain MSH, Tornetta P III), pp. e-book markers P.327-P.336.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision; recommended for internal fixation devices; redose after 4 h; duration under 24 h for most procedures. academic.oup.com/ajhp/article/70/3/195/5112717
  • Operative Techniques in Orthopaedic Surgery 3e, Vol 1, posterior wall acetabulum chapter, pdf p. 1056: indomethacin 25 mg orally three times a day for heterotopic ossification; drain till under 30 ml per 24 h; foot-flat weight bearing (about 30 lb) for 3 months.

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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