PREOPERATIVE DIAGNOSIS: Degenerative arthritis of the left hip. POSTOPERATIVE DIAGNOSIS: Degenerative arthritis of the left hip.

OPERATIVE PROCEDURE: Cemented left total hip arthroplasty. ANESTHESIA: General endotracheal anesthesia. ESTIMATED BLOOD LOSS: 300 mL of fluids. FLUIDS: Crystalyte plus 1 unit of autologous blood. COMPLICATIONS: None. INDICATIONS: The patient was a 75-year-old male with progressive left hip and thigh pain with significant degenerative arthritis on radiographs. He was brought the operating room at this time for a cemented left total hip arthroplasty. OPERATION: Following general endotracheal anesthesia, the patient was given 1 gram of IV Kefzol. He was placed in the right lateral decubitus position with the left hip upper most and the beanbag was inflated to hold him in that position. The left lower extremity was then prepped and draped in the usual sterile fashion. A standard posteriolateral approach was made with an incision extending along the femoral shaft centered over the greater trochanter incurring posteriorly at its proximal extent. Incision was carried down through the subcutaneous tissues to the overlying fascia. The fascia was sharply entered and opened the length of the incision with a Mayo scissors. The muscle was bluntly split exposing the greater trochanter and the surrounding abductors. The piriformis was identified with a periosteal elevator tagged, and removed from the bone with electrocautery. The conjoined tendon was also a distinct structure and it, too, was tagged and removed with electrocautery. The quadratus was removed from the proximal femur with electrocautery and the lessor trochanter was identified. Capsulotomy and capsulectomy was then performed. A Steinmann pin was driven into the iliac crest and a ruler was then used to measure the distance to a mark on the greater trochanter. This distance was recorded. The hip was then dislocated and the neck was cleaned of soft tissue debris with a rongeur and knife. An appropriate size neck cut was selected, and with the oscillating saw, the neck cut was made with the appropriate angle. The head was then removed. The acetabulum was exposed and soft tissue debrided sharply and with curette. Reaming was started with a 48-mm reamer and sequentially reamed up to a 56-mm. Good bleeding cancellous bone was obtained in this manner. The capsule was sharply debrided during good exposure and no soft tissue interposition into the acetabulum. After the acetabulum was prepared, and cysts were checked for with a curette, the acetabulum was irrigated with a waterpick, and packed with a Ray-Tec sponge. The cement was then mixed, and a 56-mm Osteonics acetabular component with a 32-mm outer diameter shell with a 20-degree overhang, was cemented in using standard technique. The surrounding cement was removed with a femoral elevator until there was no loose cement which would impinge on motion. After the cement had hardened, a second Ray-Tec sponge was placed in the cap. Attention was then directed to the femoral side.

The neck was further debrided of the soft tissue. An osteotome was used to start our cut in the proximal femur. A reamer was then sequentially placed down, and reamed up to a #10 cemented reamer. The canal was then broached successively up to a #10 broach, which was tight but did shift. A trial prosthesis was placed in and found to have a good fit. The neck cut was trimmed and the calcar reamer was utilized to smooth out the calcar region. A large Buck plug was placed at the appropriate depth from the medial calcar. The canal was then brushed and irrigated and lavaged with the waterpick. A vaginal pack was placed in the canal and 2 packs of cement were mixed. With the cement gun, the cement was placed in the depth of the femoral canal and pressurized. A #10 Osteonics stem with a 32-mm head with a neutral neck was then pressed into the canal. The excess cement was removed and the component held for approximately 10 minutes. During this period of time, any free cement was identified and removed. After 10 minutes, the area was further inspected for any free cement. Reduction was carried out and our leg-lengths were equal to those preoperatively. The wound was then irrigated once more, checked for any soft tissue impingement or cement. The external rotators, which had been removed previously, were sutured back through the abductor tendons, with #1 nylon. The 2 medium Hemovac drains were then placed within the wound. The overlying fascia was closed with #1 nylon. The subcutaneous tissues were closed with 2-0 Vicryl and the skin was closed with staples. Sterile surgical dressings were applied. The patient was transferred to his stretcher with an abduction pillow in place. He was then wheeled to the recovery room in stable condition. PLAN: The patient will start with the routine protocol for a cemented total hip arthroplasty via posterior approach. He will be allowed to weight-bear as tolerated. Hip flexion will be limited to 60 degrees.