Once the patient is placed in the lateral position, prepped & draped out & a surgical time-out is performed, and a slightly curved incision centered over the greater trochanter is made with a 10-blade. The incision will be extended following the femoral shaft to approximately 10 cm distal of the greater trochanter. Don’t forget to put up lap sponges.
When the patient is being draped I am passing off my cords as quickly as I can. Ioban will be placed over the incision site (I keep my scissors close so they can grab them if I’m still passing off drapes-same for the marker) & then a marker will be used to draw out the incision. The skin knife (10-blade) will be used first, and then a deep skin knife once he has dissected down enough. He will use a bovie to dissect down, as well as heavy pickups. Make sure to have your lap ready to grab any tissue he hands you. Once deep enough, rakes will be used to retract, as well as a Hibbs retractor.
The fascia is divided with the scissors over the center of the greater trochanter. Once the fascial incision is extended to expose the insertion of the gluteus Maximus on the posterior femur, the Charnley hip retractor can be positioned. This is the large U-shaped retractor. I place the extra pieces on the side of my basin on my back table. Our surgeon likes to use the smaller pieces. I keep two wet towels in my kidney basin, which is where I keep my scissors & marker for them to reach. The wet towels are opened up & placed so that the patient is protected from the retractor. I also keep their extra pair of gloves in reach as well. They take off their top pair of gloves after they’re done draping & put on a new pair. If I’m not done throwing off my cords, I leave them where they can reach them. I take them out of the wrappers so there is less garbage on the field & once less things to have to mess with & get in the way.
The short tip & cap for the bovie may be switched out for a long tip & long cap (if the surgeon prefers it).
After this, the knee will be flexed and the hip joint is internally rotated.
#1 Nurolon suture will be used to tag the rotators to help identify them at the end of the procedure. Our surgeon throws about 3-4 stitches & tags them.
Hohmann retractors are used to expose the entire joint capsule. A long knife handle will be needed to incise the capsule.
The hip joint is then dislocated, flexed, adducted, and gently rotated. A bone hook is used to help lift the femoral head out of the acetabulum. The oscillating saw will be used to cut & remove the femoral head. The green femoral osteotomy guide will then be used to measure the femoral head to see which size is needed for the implant. (be careful not to drop the head through the hole & onto the floor. I always do this over my field, just in case! The surgeon dropped ours on the floor during our last case & was not pleased with himself!!)
The foot is lowered toward the floor & and eternally rotated to expose the proximal end of the femur. A femoral neck elevator (Mickey Mouse ears) will be used to deliver and stabilize the femur during the femoral preparation. Hohman retractors are used and the femoral end is visualized to determine if bone and soft tissue needs to be removed with a rongeur. Always have a lap sponge ready to collect any tissue from the rongeur.
The T-handle intramedullary canal reamer is used to start the opening & expose the femoral canal opening. Next, a one-piece box chisel is used to remove the medial portion of the greater trochanter and lateral femoral neck in preparation for reaming.
The surgeon now begins using reamers attached to the power reamer to further open the canal. Reaming is continued until the cortical bone is reached. 3 different-sized reamers are used.
Femoral broaches (rasps) are used next. (each broach has a colored dot on the bottom of it to match the other components to it for trial) Our surgeon always cements, so the cemented broaches are used, starting out with the lowest number (2) & going up from there. Announce each number broach as you hand it to the surgeon. As well as a mallet to mallet the broach in & take it out. The final broach is seated & serves as the femoral trial component. A calcar reamer may be used, starting with the smallest one & moving onto the largest.
The surgeon may or may not use the trial components. Ours sometimes skips to the implants & has me start mixing up the cement.
The pulse lavage will be used, as well as the brush tip, which will be chucked up with the key. The cement restrictor is placed in the distal portion of the femoral canal to prevent cement from entering the nonreamed portion of the medullary canal. The cement restrictor (small plastic clear piece) is placed on the end of the insertion device. Make sure to have Freers available to help remove the cement as they are placing the implants.
The surgeon will suture with the rest of the Nurolon & then 2-0 Vicryl (or whatever their preference is). Ours will use Betadine on a sponge stick & then staple the rest. Wet & dry laps are used. A large aquacel is placed. A drain may or may not be used. We don’t normally use one for these. Then it is wrapped.
Normally we have a rep that will point things out to us & let us know what’s next, but we did not for this since it was on call & they decided not to call one, I guess. I did have a scrub tech that did help me with anything I was unsure about & our surgeon is always wonderful about coming over & helping with the implants once I have them.