Total Hip Arthroplasty (THA)
Right [left] hip [osteoarthritis / avascular necrosis / post-traumatic arthritis / inflammatory arthritis / hip dysplasia], end-stage, not responsive to conservative management
Same
Right [left] total hip arthroplasty via [posterior / direct anterior] approach, [implant manufacturer/model]
[***, MD/DO]
[Resident/PA name]
Spinal [/ general endotracheal]
The patient is a [age]-year-old [male / female] with end-stage right [left] hip [osteoarthritis / avascular necrosis] presenting with refractory hip pain and functional impairment refractory to at least [3] months of conservative management including physical therapy and analgesics. Radiographs demonstrate loss of joint space, subchondral sclerosis, and osteophyte formation. The risks, benefits, and alternatives including infection, dislocation, leg length discrepancy, nerve injury (sciatic, femoral, lateral femoral cutaneous), vascular injury, periprosthetic fracture, aseptic loosening, and need for revision were discussed. Informed consent was obtained.
The femoral head was [spherical / flattened / osteophytic]. Articular cartilage was absent with eburnated bone on both the femoral head and acetabulum. The femoral head measured [X] mm in diameter. Implants: [X]-mm hemispherical acetabular shell at [X°] inclination/[X°] anteversion; [X]-mm [polyethylene / ceramic] liner; [X]-mm femoral stem; [X]-mm [ceramic / cobalt-chrome] femoral head.
[POSTERIOR APPROACH:]
The patient was positioned in the lateral decubitus position with the operative hip up. A [X]-cm posterior incision was made centered over the greater trochanter. The fascia lata was incised. The piriformis, conjoint tendon (superior gemellus, obturator internus, inferior gemellus), and upper portion of the quadratus femoris were tagged and divided at the greater trochanter. The sciatic nerve was protected by retractor placement deep to the short external rotators[, its position confirmed by palpation]. The posterior capsule was incised and the hip was dislocated posteriorly by internal rotation, adduction, and flexion.
The femoral neck was cut at the planned level with an oscillating saw. The femoral head was removed and measured. The acetabulum was prepared with sequential reamers to [X] mm. A press-fit [X]-mm acetabular shell was impacted at [X°] inclination and [X°] anteversion (targeting 40° inclination and 15–25° anteversion for posterior approach). [X] screws were placed for additional fixation. A [cross-linked poly / ceramic] liner was impacted.
The femoral canal was prepared with the broach sequence to size [X]. The femoral stem was trialed and leg length, offset, and stability assessed. The final [uncemented / cemented] [X] stem was implanted. A [X]-mm head was assembled. The hip was reduced and stability tested through [0–90° flexion] with no impingement.
The posterior capsule and short external rotators were repaired to the posterior greater trochanter with [No. 2 FiberWire] sutures through bone tunnels. The fascia lata was closed with [#1 Vicryl]. Skin was closed with [staples / 3-0 Monocryl].
None
Femoral head sent to pathology [if indicated]
[X] mL
None [Routine closed-suction drains are not recommended for primary THA per current evidence]
The patient was taken to the PACU in stable condition. Weight-bearing as tolerated. [Posterior approach: posterior hip precautions per surgeon preference — current evidence does not require routine precautions after posterior approach THA with capsular repair.] DVT prophylaxis initiated. Physical therapy initiated on postoperative day 1.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Right/Left hip ***, end-stage
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left THA, *** approach, *** implant
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Spinal
INDICATIONS: .PTAGE-year-old .PTSEX with end-stage hip ***, failed *** months of conservative management. Consent obtained.
FINDINGS: Femoral head ***. Cartilage absent, eburnate. Implants: *** mm cup at ***°/***°, *** liner, *** stem, *** mm head.
PROCEDURE:
Lateral decubitus, operative hip up. Posterior incision. Fascia lata incised. Short external rotators (piriformis, conjoint tendon, upper quadratus femoris) tagged and divided. Sciatic nerve protected deep to the short external rotators [palpated]. Posterior capsule incised; hip dislocated posteriorly (IR/adduction/flexion). Femoral neck cut at planned level. Head removed, *** mm. Acetabulum reamed to *** mm; *** mm shell impacted at ***°/***°; *** screws. *** liner impacted. Femoral canal broached to size ***. Trial: stable, LL/offset confirmed. Final stem implanted. Head assembled. Hip reduced; stable. Posterior capsule and short external rotators repaired to GT via bone tunnels (No. 2 FiberWire). Fascia lata closed. Skin closed.
EBL: *** mL
COMPLICATIONS: None
DISPOSITION: WBAT. DVT prophylaxis. PT POD 1.
Signed: .ME, .MYDEGREE
.TODAYVariants
Direct anterior approach (DAA)
The patient is positioned supine on a [traction / standard] table. An anterior incision is made in the interval between the tensor fascia lata (TFL) and sartorius, utilizing the Smith-Petersen internervous plane (femoral nerve supplies sartorius; superior gluteal nerve supplies TFL). The lateral femoral cutaneous nerve is identified and protected — LFCN injury is the most common approach-specific complication. The hip capsule is incised in [T / H / inverted-T]-fashion. Hip dislocation is achieved with traction, external rotation, and hyperextension. Acetabular and femoral preparation proceed as in posterior approach. DAA preserves the short external rotators and posterior capsule, avoiding posterior hip precautions. Capsular repair or preservation at closure is recommended. Note: early functional advantages over posterior approach (with capsular repair) are modest and equalize by 3 months in randomized trials.
Hip hemiarthroplasty — fracture
Document the patient's functional status and rationale for hemiarthroplasty vs. THA. Hemiarthroplasty: only femoral component and bipolar head are implanted; native acetabular cartilage is retained.
Charting Tips
- Document cup inclination and anteversion with actual intraoperative measurements. The Lewinnek 'safe zone' (40° ± 10° inclination, 15° ± 10° anteversion) is a widely used reference, but contemporary evidence (Abdel et al. 2016) shows most dislocations occur within this zone — functional/spinopelvic positioning also matters. Document the measured angles; do not just write 'safe zone placement.' Acetabular malposition is the leading cause of instability and polyethylene wear failure.
- Document posterior capsule and short external rotator repair for posterior approach. This step is most important for reducing posterior dislocation risk. Document technique (bone tunnels vs. suture anchors vs. direct capsulorrhaphy), suture type/size, and that repair was completed. Capsular repair significantly reduces posterior dislocation rates compared to unrepaired posterior approach.
- Document sciatic nerve protection for the posterior approach. Post-THA sciatic palsy is a known complication and a frequent source of litigation. In a primary case the nerve is protected by keeping the released short external rotators as a cuff over it and the posterior retractor on bone deep to them, so document what was actually done: 'the sciatic nerve was protected deep to the short external rotators (position confirmed by palpation).' In revision or dysplastic anatomy the nerve is formally identified and tagged, and that should be documented as such.
- Document leg length and offset comparison. Leg length discrepancy greater than 1 cm is a common source of patient dissatisfaction and litigation. Document intraoperative assessment method (preoperative template, intraoperative caliper from fixed pelvic pin to femur, fluoroscopic check) and final result relative to contralateral side.
- Document implant UDI and full specifications. FDA UDI tracking is mandatory for hip prostheses (Class III devices). Record manufacturer, model, lot number, component sizes, and unique device identifiers for cup, liner, femoral stem, and femoral head. AJRR participation is voluntary but strongly encouraged.
Documentation & Reimbursement Considerations
- Report Total Hip Arthroplasty (THA) as the primary service when it is the definitive operation performed.
- Document the approach, implant specifications (manufacturer, model, bearing surface, component sizes), and press-fit vs. cemented technique.
- The key requirement is a prior open surgical procedure on the same hip joint. Document the prior procedure explicitly.
- Reporting selection requires documentation of which component(s) were explanted and reimplanted. Staged-or-related-procedure reporting (staged procedure) applies if planned as a staged procedure within the prior 90-day global.
- Implant documentation: FDA UDI (unique device identifier) tracking is mandatory for Class III implants including hip prostheses. Record manufacturer, model, lot number, component sizes, and UDI for cup, liner, femoral stem, and head for every case. The American Joint Replacement Registry (AJRR) is voluntary — not a state mandate. Mandatory FDA UDI documentation and voluntary AJRR participation are separate requirements.
- 90-day global period. Closed reduction of dislocation under anesthesia within the global period uses related unplanned return-to-the-operating-room reporting (unplanned return to OR for complication). Second-stage revision (planned staged procedure) within the global period uses staged-or-related-procedure reporting. Unrelated-procedure reporting during the postoperative period applies to unrelated procedures during the global period. Related unplanned return-to-the-operating-room reporting does not reset the global period.