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Orthopedics

PROCEDURE: Arthroscopically Assisted Anterior Cruciate Ligament Reconstruction With Autogenous Central Third Patellar Bone-Tendon-Bone Graft, Left Knee

The patient was brought to the operating theater after epidural anesthesia was induced by the anesthesia team in the holding area. Prophylactic antibiotics were administered, and the patient was placed in a supine position on the operating room table. Examination under anesthesia revealed a range of motion from 0 to 120 degrees. With slight manipulation, there was an audible pop of an adhesion allowing flexion to 130 degrees without difficulty. There was a 2+ Lachman with a soft end-point, a positive pivot shift test, and no varus or valgus instability.

The left knee was then prepped and draped in the usual sterile fashion. Through a longitudinal anterior knee incision over the central portion of the patellar tendon measuring approximately 4 cm in length, the central third patellar tendon graft was obtained. It measured 10 mm in width, both the bony and tendinous portions; the length was measured to be 28 and 30 mm, respectively. The defect site was then thoroughly irrigated, and the patellar tendon was reapproximated with 1-0 Vicryl stitches in an interrupted fashion. Standard arthroscopy portals were made: one superior and lateral, two in the infrapatellar region, one medial, and one lateral. The joint was infused and expanded with sterile saline. All compartments of the joint were thoroughly examined.

The patellofemoral joint was pristine as was the suprapatellar pouch. The medial compartment was next examined. It revealed a dissolving PDS meniscal repair stitch as well as a healed meniscus without any evidence of tear or subluxation of the meniscus in its entirety. The intercondylar region was next examined and revealed remnants of a scarred and torn anterior cruciate ligament which was completely nonfunctional. The PCL was intact. The lateral compartment was next examined. The lateral meniscus repair was also well healed with dissolving vertical mattress PDS stitches visible. There were no subluxation or tears in the lateral meniscus.

Attention was redirected to the notch region as the graft was prepared on the back table for insertion with heavy Ethibond and drill holes through the bony ends by the assistant surgeon. Using a basket shaver and a large bur, the remnants of the ACL were removed all the way back to the over-the-top position, and a notchplasty was performed using a round bur. The anatomic attachment site was identified a few millimeters anterior to the posterior cortex and lateral femoral condyle and marked for later seating of the graft. At this point, using the tibial alignment guide, a guide pin was then passed with the notch just anterior to the PCL so as not to impinge anteriorly.

Once this was accomplished, a small lateral incision was made over the IT band. The wound was deepened through the subcutaneous tissue. Using an over-the-top passer in a retrograde fashion, the guide was brought into the notch posteriorly. A guide pin was passed into the previously marked anatomic attachment site on the femur. A 10-mm cannulated reamer was passed over the guide pin, and the edges were chamfered. In addition, a 10-mm cannulated drill was passed over the tibial guide pin. There was also chamfer cleaning of remnants of the ACL with the shaver. The graft was then passed proximally and distally through the femur, through the notch, and then out through the tibia. This was secured proximally with a 9 x 25-mm screw. With the knee held in approximately 20 degrees of flexion and the graft under tension, an additional 9 x 25-mm interference screw was used to secure the graft on the tibial side. The knee was brought through a range of motion from 0 to 90 degrees without impingement and with excellent tension of the graft.

A small additional notchplasty was performed to ensure adequate clearance on full extension. Once this was accomplished, all of the wounds were thoroughly irrigated. The peritenon was closed with 2-0 Vicryl as well as the subcutaneous tissue with 2-0 Vicryl. The skin was closed with 4-0 running PDS and Steri-Strips. Pressure dressing, PolarPack, and hinge knee brace were applied. The procedure was concluded. The patient was taken to the recovery room in stable condition having tolerated the procedure quite well. No complications.

OPERATIVE PROCEDURE: Open Reduction-Internal Fixation With Synthes One-Third, Semitubular Plate and 3-M Staples

The patient was brought to the operating room, placed in the supine position, and given a spinal anesthesia. The right ankle was then prepped and draped in the usual sterile manner. The operation was performed under tourniquet control.

An incision was made laterally over the distal fibula. Initial incision went through skin and subcutaneous tissue. Bleeders throughout the procedure were treated, clamped, and electrocoagulated. The fascia was then incised, and the fracture was identified. The fracture ends were cleared and clamped in anatomic position. A 6-hole, 1/3, semitubular plate was then placed posterolaterally and transfixed with the screws. Anatomic position was achieved.

We then proceeded medially, where a short incision was made over the medial malleolus. Initial incision went through skin and subcutaneous tissue. Bleeders throughout the procedure were treated, clamped, and electrocoagulated. The fascia was incised, and a large medial malleolar fracture fragment was identified. The fracture was freshened and then clamped. Three 3-M staples were then used to transfix the fracture. Intraoperative x-rays were then taken, AP and lateral, which showed anatomic position of all fractures with the ankle joint in anatomic position.

The wound was then thoroughly irrigated. Both sides were closed with 3-0 Dexon, subcutaneous tissue with 2-0 Dexon, and skin with the skin clips. A compressive dressing was applied followed by the application of a short leg cast.

OPERATIVE PROCEDURE: Left Carpal Tunnel Release

After adequate Bier block anesthesia was obtained, the left upper extremity was prepped and draped in the usual fashion.

A small incision was made at the base of the thenar eminence just distal to the volar flexion crease of the wrist. The subcutaneous tissue was bluntly divided. Bleeders were controlled using electrocautery. The palmar fascia was dissected using Stevens scissors. The volar carpal ligament was identified, and a clamp was placed from distal to proximal within the carpal canal to protect the underlying structures. The volar carpal ligament was cut on the underlying clamp in its entirety. Digital and visual examination of the volar carpal ligament was carried out at this time, and complete release of the volar carpal ligament was completed using the Stevens scissors. Examination of the median nerve revealed a moderate hourglass compression-type deformity secondary to volar carpal ligament pressure.

The wound was irrigated using sterile saline. The subcutaneous tissue was closed using one interrupted 3-0 undyed Vicryl, and the skin was closed using a combination of simple and mattress 3-0 nylon sutures. A compressive sterile dressing was applied. The tourniquet was released; neurovascular status of the extremity was intact in the recovery room.

OPERATIVE PROCEDURE: Arthroscopy/Partial Medial Meniscectomy Right Knee

The patient was first personally identified in the holding area and brought to the operating room. After an adequate general anesthetic was achieved with the patient in the supine position on the operating room table, the right lower extremity was prepped and draped in the usual sterile fashion with the prep consisting of Betadine scrub followed by Betadine solution.

The knee was examined under anesthesia first, and there was found to be a positive Lachman's, but a negative pivot shift and negative varus and valgus stress in flexion and extension. There was found to be some lack of terminal extension also passively on examination. The patellar tendon was palpated, and just medial and lateral to it, longitudinal incisions were made at the level of the joint line with #15 blade going through skin and dermis. Similarly, the superomedial aspect of the patellar femoral joint was palpated and incision was made with the #15 blade at this level.

At this point, the knee joint was inflated with 60 mL of normal saline. The dull trocar was used to introduce the sheath in the superomedial portal, which was then hooked up to the ingress and inflow. Inflow was used with gravity. The table was then flexed. The arthroscope was introduced by way of the sheath, after the dull trocar was used to introduce it into the lateral compartment. The arthroscope was then introduced over the sheath, and arthroscopy in the lateral compartment was carried out.

The lateral compartment was found to be within normal limits without any evidence of chondromalacia of the distal femur or proximal tibia, and the lateral meniscus was found to be intact on its anterior portion.

The lower extremity was placed in a figure-of-four position allowing examination of the posterior horn of the lateral meniscus, which was found to be without any evidence of tears. The knee was brought back into neutral position. The arthroscope was then brought into the intercondylar notch, where there was found to be evidence of a hemorrhagic anterior cruciate ligament and what appeared to be a normal posterior cruciate ligament.

Arthroscopy was then continued into the medial joint, where the anteromedial extent of a bucket-handle meniscal tear was identified. This was found to be in the white zone of the medial meniscus without any evidence of vascularity.

The probe was introduced through the medial portal after using a dull trocar to widen the portal. A probe was used to probe the bucket-handle tear and define its extent, as well as probe the remainder of the medial meniscus which was found to be stable and intact to probing.

At this point, a forward-biting basket was introduced into the medial portal, and the anterior medial portion of the bucket-handle cartilage tear was resected, allowing it to be free on its posterior limb. At this point, a spinal needle was used to position an accessory medial portal. It was visualized within the medial compartment at an angle and trajectory which was good for resecting the remainder of the bucket-handle tear.

At this point, a #15 blade was used to go through skin and dermis, and a dull trocar used to open the portal. A Kocher curved clamp was introduced into the original medial portal and was used to grasp the remaining bucket-handle fragment. Through the accessory medial portal, the scissors were introduced, and attempts were made to trim the remaining portion of the cartilage tear. This was found to be difficult; at this point, the cartilage tear was released of the Kocher, and the shaver introduced through the medial portal. Shaving was then carried out to balance the remaining rim of the medial meniscus. The remaining portion of the bucket-handle tear was resected with the shaver.

At this point, the shaver was removed, and arthroscopy in the intercondylar notch was carried out once again. The probe was placed around the anterior cruciate ligament, and probing of the anterior cruciate ligament revealed it to be intact, although it was hemorrhagic. It appeared to have stable femoral and tibial attachments.

At this point, the patellofemoral joint was examined as the arthroscope was brought up into the suprapatellar pouch and the leg brought into extension. The patellofemoral joint was found to be within normal limits without evidence of osteochondral lesions. The arthroscope was brought down back through the medial compartment, where the medial gutter was noted to have no evidence of loose bodies. Similarly, arthroscopy was carried out across into the lateral joint once again and into the lateral gutter, where no loose bodies were appreciated.

The arthroscope was removed. Suction was used to irrigate the knee joint out through the superomedial trocar. The instrumentation was then removed. The wounds were closed with 4-0 nylon interrupted suture.

A mixture of Toradol, morphine, and Marcaine was introduced into the patellofemoral joint medially for postoperative analgesia. Sterile dressings were applied.

OPERATIVE REPORT: Repair of Tear Rotator Cuff, Impingement Syndrome Left Shoulder

Under general anesthesia, intubated and in a semisitting position, the patient's right shoulder was prepared and draped in a sterile manner.

Standard saber-cut incision was then made and carried down through subcutaneous tissues. Bleeders were clamped and electrocoagulated with electrocautery. The deltoid muscle was retracted laterally, and the anterior shoulder cuff and joint were exposed. It was noted at the time of exposure that there was a great deal of adherence between the rotator cuff itself and the overlying bursa. The bursa itself was excised, and it was immediately noted that the coracoacromial ligament was markedly thickened and impinging on the shoulder joint, even at rest.

As the subacromial bursa was excised, approximately 40 mL of fluid exuded from the joint. It was clearly evident that he had a very large tear with avulsion of the supraspinatus from the greater tuberosity. The coracoacromial ligament was excised. It was then noted that he had a large osteophyte under the clavicle in the area of the acromioclavicular joint, and the acromion, itself, was forward sloping and also impinging on the joint.

Using a bur and Surgitome, protecting the remaining portion of the joint with the retractor, an approximately 1/8 inch of the acromion was excised. This was extended from the tip of the acromion back to the acromioclavicular joint and across the joint involving the osteophyte from the acromion. Soft tissue was removed using a rongeur. The edges were noted to be quite smooth, thereby, immediately allowing more space for the shoulder joint itself.

Using 1-0 Vicryl figure-of-eight sutures, it was possible to repair the rotator cuff, bringing the tendinous portion back to its attachment at the area of the greater tuberosity. This area was roughened to allow faster healing. Good repair was attained. There was some tension, and this was reinforced with more suture material.

The wound was irrigated with antibiotic solution and then closed using 2-0 Vicryl for the subcutaneous tissue and skin staples for the skin. The sling-and-swathe was applied. The patient was then taken to the recovery room in satisfactory condition.

OPERATIVE PROCEDURE: Total Knee Replacement (Arthroplasty)

The patient was brought to the operating room and placed on the operating table in the supine position. A sandbag was then positioned for maximal knee flexion of the right knee and then taped in position. The right knee was then elevated, and a pneumatic tourniquet, pretested at 350 mm Hg, was placed around the right upper thigh. The right leg was then prepped and draped free.

The preoperative vancomycin intravenous drip was completed. The leg was then elevated and exsanguinated with the use of an Esmarch bandage, and the tourniquet was then inflated.

A midline incision, beginning 3 cm proximal to the superior pole of the patella as well as inferior to the inferior pole of the patella, was then performed with a #20 scalpel through the skin. Meticulous hemostasis was obtained with electrocautery. Dissection was taken down through the same line to the level of the quadriceps tendon, the patellar periosteum, as well as the patellar tendon.

Undermining of the skin flaps to expose the medial and lateral retinacula was then performed, and a paramedial retinacular incision was then performed with a separate #20 scalpel through the midline of the quadriceps tendon, through the medial border of the patella, and down to the level medial to the patellar tendon. The patella was then everted, and the retropatellar fat pad was then excised.

Proximal medial periosteal elevation of the proximal tibia was then performed, and the patella was then everted and flexed. Angle bone spikes were placed into the medial and lateral gutters of the knee with soft tissue debridement of the cruciate ligament and the meniscal bodies, which were then sharply resected and removed.

A Hohmann retractor was placed posteriorly and centrally and anteriorly displaced the tibia. An external tibial alignment guide was then placed around the leg. The highest point of the medial articular surface was then chosen with a stylus. A 5-degree, posteriorly angled, cutting jig was then fixed to the anterior surface of the proximal tibia with transfixion pins.

After this was performed, the alignment device was removed, and the cutting jig was left in place. The oscillating saw was used to resect 4 mm of proximal bone. After this had been performed, the jig and the pins were removed. The rest of the soft tissue of the proximal tibia and menisci were removed as well.

After further irrigation, attention was then shifted to the femur. A step drill was placed anterior to the insertion of the anterior cruciate ligament, and a 0.25-inch drill hole was then placed up into this area, connecting with the intermedullary canal. An intermedullary alignment guide was then placed at 70 degrees of valgus for the right knee and driven up into place. An appropriate amount of rotation was then determined, and the jig was then pinned in place into the distal femur. After this had been performed, a provisional anterior cutting jig was fixed to this, and an oscillating saw was used to make the provisional anterior cut. The alignment of this cut was noted, and the 70 degrees of valgus was deemed acceptable.

The distal femoral cutting jig was then applied to this intramedullary device and pinned into position. The intramedullary device was then removed. A distal cutting jig was used for an 8-mm cut, and the appropriate amount of medial and lateral condyle was removed.

At this point, sizing of the femoral cuts measured approximately a size 7 femur and a size 7 tibia. The anterior, posterior, and chamfer-cut jigs were then fixed to the distal portion of the femur, and the appropriate cuts were made with an oscillating saw. Both 8-mm and 10-mm spacer blocks were placed in both flexion and extension, with adequate ligamentous tensing and full extension with the 8-mm block only. The trial prosthesis was then placed on the femur, and adequate seating with all the cuts had been noted. Attention was then turned to the 2 distal drill holes. With a 0.25-inch drill bit, drilling was done into the distal medial and lateral portions of the condyle, and a notch-cutting jig was then placed after the trial prosthesis was removed. The notch was then cut, both medially and laterally as well as from anterior to posterior, and removed with an osteotome. The trial prosthesis was then reinserted, and a #7 tibial tray and an 8-mm spacer were then placed on the tibia. A trial reduction was performed. Adequate ligamentous tension and extension were noted.

At this point, the notches on the anterior portion of the tibia were then marked with a Bovie for appropriate rotation, and the trial was removed. The template was then pinned in place in appropriate position, and the press-fit fins were then performed with a cutting jig through the template. After this had been performed up to the appropriate size #7, all cutting components were removed, and a trial with a posterior-stabilizing stem was then placed and found to have adequate fixation.

Attention was then shifted to the patella. Debridement around the patellar surface was performed, and a patellar cutting jig was placed into position. The measurement of the depth of the patella was 24 mm, and the appropriate spacing device was then used. An oscillating saw was used to make the cut. A size #11 was noted to be the appropriate-sized patellar button. It was noted on his natural bone that there was medial shift of the ridge of the patella.

Three drill holes were then placed in the bone. A trial button with a medial shift, size #11, was fixed, and the depth of the total component and remaining bone was 24 mm. Reduction was then performed, and adequate tracking was noted as well. All trial components were removed, and irrigation was performed. Two packages of methyl methacrylate were mixed. The insertion components, a size #7 femur with posterior stabilizing and a size #7 tibial tray with press-fit fins, were chosen. A size #11 patellar button was chosen.

Irrigation with pulse lavage with 3 L of normal saline with 50,000 units of bacitracin was used, and the joint dried.

The patellar button was inserted first and clamped into position. The femoral component was then cemented into position and impacted. The tibial tray was then cemented into position and impacted with some force. A trial tibial spacer was placed in and the knee brought into extension. Adequate alignment was noted at this point. After further debridement of any loose and/or extruded cement, the knee was irrigated. The final posterior-stabilized tibial spacer was then inserted. The knee was again irrigated.

Closure was then performed over 2 drains. The retinaculum and quadriceps mechanism were repaired with figure-of-eight sutures of 1-0 Vicryl. The subcutaneous layer was closed meticulously with 2-0 Vicryl, and the skin with stainless steel staples.

The patellar tracking was noted to be even, and there was no subluxation. One drain was noted to be pulled out as the dressing was being applied. This was then clamped and tied shut. A sterile compressive dressing was applied. The tourniquet was deflated at 96 minutes. The knee was then placed in a knee immobilizer.

OPERATIVE PROCEDURE: Total Hip Replacement

DATE OF SERVICE: 99/99/99

PREOP/PROCEDURE DIAGNOSIS: Avascular necrosis with early degenerative arthritis of the left hip.

POSTOP/PROCEDURE DIAGNOSIS: Avascular necrosis with early degenerative arthritis of the left hip.

OPERATION/PROCEDURE: Left Meridian total hip replacement.

SURGEON/PHYSICIAN: ORTHOPEDIC SURGEON, MD
ASSISTANT: ORTHOPEDIC SURGEON, MD
ANESTHESIOLOGIST: ANESTHESIOLOGIST, MD
ANESTHESIA: General.

DESCRIPTION OF OPERATION/PROCEDURE: The patient was brought to the operating room and, after satisfactory anesthetic induction and intubation, was turned into the lateral decubitus position and held there with a Montreal pegboard and airplane arm splint. The leg was then prepped from toes to umbilical level in routine manner, following which it was draped free, occluding the perineum and operative areas with adhesive Ioban Vi-Drape.

The skin incision was made in the axis of the shaft of the femur to the tip of the greater trochanter and slanted backward in the direction of the fibers of the gluteus maximus. The skin incision was carried through subcutaneous tissue down to fascia. After hemostasis, the fascia was divided in the direction of its fibers, splitting the fibers of gluteus maximus superiorly. After hemostasis, anterior and posterior flaps were raised, and the Charnley retractor was placed.

The upper one half of the gluteus maximus tendon was then incised. The interval between the piriformis and the inferior border of gluteus minimus and medius was then identified, and a retractor placed deep beneath gluteus minimus. Gluteus minimus was then retracted off the underlying hip capsule. The piriformis tendon was identified and cut close to its attachment in the piriformis fossa of the greater trochanter by internally rotating the leg. The gemelli were then cut close to their attachments, and the incision was carried down to the upper portion of the quadratus femoris at the level of the lesser trochanter. After hemostasis, this incision was carried down to the underlying capsule, which was freed from its attachment to the intertrochanteric ridge and to the base of the neck. On entering the hip joint, the capsule was dissected further to allow the capsule to be lifted with the overlying short rotators. A T-incision was then made through the capsule immediately beneath the tendon of piriformis, and this was carried down to the labrum of the acetabulum. The inferior and superior capsular flaps were then raised with the overlying short rotators to expose the femoral neck and head. Further dissection of the inferior capsule down to the level of the lesser trochanter allowed a finger to be passed around the femoral neck inferiorly.

The hip was then dislocated after further incision into the superior capsule. By internal rotation and adduction, the head was delivered from the acetabulum into the wound. A wide Hohmann retractor was then placed underneath the femoral neck. Some remnants of short rotator were excised from the posterior aspect of the greater trochanter, allowing visualization of the femoral neck. Using the head and neck cutoff guide, the femoral head and neck were removed at the appropriate level. The wide Hohmann retractor was removed. Attention was directed to the inferior and anterior capsule.

Using a combination of electrocautery and capsular scissors, anterior and inferior capsulotomy was performed. On completing this capsulotomy, the hip was then rotated to about 45 degrees of internal rotation. Placing the knee back on the table, a Hohmann retractor was then placed over the anterior margin of the acetabulum, and the femur retracted forward exposing the anterior rim of acetabulum. Electrocautery was used to remove redundant anterior capsule and to excise the labrum and remnants of labrum superiorly and posteriorly. Posterior capsule was preserved. The contents of the acetabular fossa were removed by electrocautery and curettes.

An inferior retractor was then placed outside the transverse acetabular ligament by the ischium, retracting the anterior soft tissues. This allowed visualization of the cavity of the acetabulum, which was then reamed with successive reamers.

A 58-mm drill guide was then used to guide 2 keyholes superiorly immediately behind the anterior inferior iliac spine. After making the 2 keyholes, cysts were curetted totally, and bone graft obtained from the debris of the reamers was introduced into the cysts and into the acetabular fossa.

The 58-mm Vitalock solid-back shell was then inserted in press-fit mode over bone paste placed into the floor of the acetabulum. The 28-mm neutral liner was then introduced with the coverage in the appropriate position posterior superiorly. The anterior and inferior retractors were removed, and attention was directed to the femur.

By a combination of adduction and internal rotation, with the Hohmann retractor placed beneath the proximal femur at the level of the lesser trochanter, the proximal femur was visualized. Electrocautery was used to remove the tendinous stump of piriformis and surrounding soft tissue to expose the lateral-most extent of the femoral neck.

A box chisel was then used to enter the proximal femur, following which the femur was reamed with successive reamers up to 14 mm. The femur was then broached with appropriate broaches. It was decided, at this time, to proceed to a 4/14-mm Meridian stem. The canal was appropriately reamed using AO flexible reamers, following which the proximal femur was broached and proceeded at the level of the neck cut.

Bone graft was then introduced down the canal, and a 4/14-mm Meridian stem was inserted in press-fit mode using a +4 mm, 28-diameter, femoral head. The hip was then reduced after thoroughly cleansing the inner aspect of the acetabulum to assure that all debris was removed. The wound was thoroughly washed, and, after reduction of the hip, the leg was placed on a metal stand in slight abduction and internal rotation. The capsule, with overlying short rotators, was then reattached to the intertrochanteric line and posterior trochanteric ridge through drill holes placed through bone. Interrupted sutures were used to secure the capsule and overlying short rotators in position. A stitch was placed through the gluteus medius tendon just above the piriformis fossa and passed through the piriformis tendon, which was then secured as close to the original origin as possible.

On completion of the closure of the short rotators, drains were placed, one deep within the hip joint itself and one superficial, and the fascia was closed with interrupted #1 Vicryl sutures. The subcutaneous tissue was closed with 3-0 Vicryl sutures, and the skin was closed with clips. Telfa dressing, 4 x 8's, and Cover-Roll completed this closure.

T.E.D. hose were applied to the patient, and the patient was then returned to the recovery room in good condition having tolerated the procedure well.

SPECIAL NOTES: The head was transected, and a large area of avascular necrosis was found. There was also some fairly significant degenerative arthritis on the surface of both the femoral head and inside the acetabulum.

Special thanks to Kirsten Chepeus for submitting this report!

NOTE: T.E.D.® is a trademarked name (manufacturer Kendall) and includes the periods (ref. "Current Medical Terminology" [Vera Pyle]). Many references (Stedman's Medical and Surgical Equipment Words, The Surgical Wordbook [Tessier]) do not include the periods.

OPERATIVE PROCEDURE: Total Hip Replacement Revision (Left)

PREOP/PROCEDURE DIAGNOSIS: Failed left total hip replacement with a loose femoral component and impingement of the edge of the acetabular rim with the psoas tendon.

POSTOP/PROCEDURE DIAGNOSIS: Failed left total hip replacement with a loose femoral component and impingement of the edge of the acetabular rim with the psoas tendon.

OPERATION/PROCEDURE: Revision of left total hip replacement, with revision of both components after removal of both components, screws and cement.

SURGEON/PHYSICIAN: ORTHOPEDIC SURGEON, MD
ASSISTANT: ORTHOPEDIC RESIDENT, MD
ANESTHESIOLOGIST: ANESTHESIOLOGIST, MD
ANESTHESIA: General.

DESCRIPTION OF OPERATION/PROCEDURE: The patient was brought to the operating table, and, after satisfactory anesthetic induction and intubation, was turned into the right lateral decubitus and held there with a Montreal pegboard and airplane arm splint. The left hip was then prepped and draped out in the routine manner, occluding the perineum and operative area with an adhesive Ioban Vi-Drape.

A posterior approach was made to the hip. The short rotators were taken down with the capsule as a single layer. The hip was then slowly internally rotated and dislocated. A retractor was placed beneath the femur, elevating this, after incising some of the inferior capsule, and bone was then removed from the trochanter directly over the lateral cement mass.

An extractor was placed over the neck of the prosthesis, and it was noted that this was grossly loose. It was slowly pulled from the cavity of the femur, and, as it came, a crack occurred in the trochanter (which was very osteoporotic). A tension-band wiring was then performed of the tip of the greater trochanter using 2 vertical K-wires and a figure-of-eight wire drilled through the lateral cortex of the femur. This brought the tip of the fractured trochanter back anatomical, and the tension band was tightened. The stem was removed completely, bringing with it most of the cement mantle. The remaining cement mantle was removed using Moreland osteotomes, and finally the entire cement mantle and the distal plug were removed.

After removal of the stem, access was gained to the inferior and anterior capsule, which was incised. The superior and anterosuperior capsule was excised, and this allowed sufficient mobility in the femur to place a self-retaining retractor between the pseudocapsule posteriorly and the trochanter, retracting the femur forward. A second retractor was placed over the anterior column, and this allowed full visualization of the acetabulum. Removing pseudocapsule exposed the bone-prosthesis interface. It was noted that there was a florid synovitis over the psoas tendon. The rim of the acetabular component, both plastic and metal, was proud of the anterior rim of the acetabulum, and, in fact, the acetabulum was slightly retroverted.

The plastic liner was then removed from the metal shelf, and, after removal of the plastic liner, the 3 screws were removed. Using the Moreland osteotomes and Smith-Petersen gooseneck gouges, the interface between bone and the acetabular component was cut, and the component was removed.

The acetabulum was then reamed in the correct position with more anteversion on the reamer down to 52 mm and a 54-mm Vitalock cluster shell was then inserted after placing bone paste into the floor of the acetabulum. The bone surrounding the acetabulum was very osteoporotic due to the presence of the prior component, and it was, therefore, felt advisable to add an augmentation screw. The wing of the ilium was somewhat soft, and the screw was then extended to 50 mm, which probably would engage just distal to the sacroiliac joint. Good fixation and good position were obtained, and a 28-mm neutral liner was then snap-fit in place in the cup.

Attention was now directed to the femur, and the femur was thoroughly cleaned. Then using a Cebotome and gouge, the pseudocortex was removed from the inside of the femur to allow interdigitation of the second cement batch. After using both "comeback curets," gouges, and rongeur, the pseudocortex was removed as much as possible. The canal was then plugged, thoroughly cleaned with a rotating brush and pulsatile lavage, dried, cement introduced from distal to proximal, pressurized, and an Exeter standard stem was introduced to the predetermined level. As the cement polymerized, all excess was removed. The head/neck length was then measured, and a +5 head was selected, which reproduced the desired neck length. After reduction, it was noted that there was no shuck present.

Closure consisted of bone grafting the trochanteric area where the crack had occurred. The pseudocapsule was sutured back to bone with interrupted sutures. The fascial layer was closed with interrupted sutures over 2 drains, one placed within the hip cavity and one more superficial, and then the subcutaneous tissue and skin were closed in separate layers. Telfa dressing, 4 x 8's, and Cover-Roll completed the dressing. The patient was returned to the recovery room in good condition, having tolerated the procedure well.

Many thanks to Kirsten Chepeus for submitting this report.