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Here is the op note. I am not sure if I should use the 11983 or the 27091, or maybe im wrong all together!
INDICATIONS: The patient has undergone hybrid left total hip
arthroplasty elsewhere and developed MRSA infection in the
postoperative period. He eventually came to removal of the total hip
arthroplasty components and placement of an antibiotic-impregnated
cement spacer. Subsequent x-rays demonstrated retention of a portion
of the distal cement from the index procedure. He is allergic to
vancomycin, and thus underwent IV treatment with daptomycin in the
postoperative period. He was sent for reimplantation of his left total
hip arthroplasty, but with the retained cement from the index
arthroplasty it was felt that repeat debridement and replacement of
articulating antibiotic-impregnated cement spacers was appropriate.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room
and a satisfactory general anesthetic induced. He was turned onto his
right side and the left hip and lower extremity prepared and draped in
the usual sterile manner. Daptomycin 350 mg IV was administered
preoperatively along with Ancef 2 grams IV. A preoperative timeout was
performed. The index exposure was a posterior approach with the
incision well posterior on the buttock. It was elected proceed with an
anterolateral approach to the hip. A longitudinal lateral incision was
made and dissection carried deeply to fascia. Fascia was divided in
line with the femur distally and at the anterior aspect of the gluteus
maximus proximally. The soft tissues about the hip were thickened,
inflamed, and edematous. The hip was exposed by releasing the anterior
half of the gluteus medius along with the anterior portion of the
vastus lateralis as a sleeve, thus skeletonizing the anterior aspect
of the proximal femur. As the hip was entered, significant amounts of
cloudy, purulent-appearing fluid were encountered. Pseudocapsule and
hypertrophic, purulent-appearing synovium were excised such that the
hip could be dislocated. An off-the-shelf antibiotic-impregnated
cement spacer had been utilized. The proximal cement was removed with
an osteotome and the spacer removed from the femoral canal. The cement
utilized to fix the spacer was easily removed in concert with the
spacer. Purulent-appearing tissue from the bone-cement interface of
the femur was sent for culture. Note that synovial fluid and hip
synovium had been sent for culture. Using cement removal tools, the
retained cement and retained distal cement plug were removed. The
femoral canal was thoroughly debrided with reverse-cutting curettes.
The femur was viewed with image radiographs in multiple planes and
there was no apparent retained cement or foreign material. The canal
was reamed to 16 mm using flexible reamers which provided cortical
chatter over a 4-cm region of the isthmus. The femoral canal was
irrigated with 6 liters of saline via pulsing lavage. The proximal
femur was prepared with reamers and broaches to accommodate a size 10
Stryker EON cemented femoral component and broach, anticipating use of
a smaller femoral component coated with antibiotic-impregnated cement.
Purulent-appearing tissue from about the acetabulum was debrided with
curettes and specimen sent for culture. The cement spacer had eroded
superiorly into the acetabulum. After thorough debridement of the
acetabulum, it was found that there were perforations superomedially,
but the anterior and posterior columns remained intact. The acetabulum
was thoroughly irrigated with 6 liters of saline via pulsing lavage.
Antibiotic-impregnated cement was mixed with 4 vials of tobramycin per
bag of cement. The acetabulum had been prepared with hemispherical
reamers and it was found that 66-mm reamer was necessary to engage
both the anterior and posterior acetabular walls in the correct hip
center position, leaving a defect superiorly. The
antibiotic-impregnated cement was packed into the superior acetabular
defect to act as a spacer. The trial 66-mm acetabular component was
applied and the cement allowed to harden. The remainder of the
antibiotic-impregnated cement was utilized to coat a size 7 Stryker
EON femoral component with a high-offset neck. With the 66-mm
acetabular trial appropriately positioned and the cement augment
having hardened about the superior acetabulum, a trial polyethylene
insert was applied along with a +0 head and the hip reduced. Note that
the size 10 femoral broach remained in place. Length, tension, and
stability appeared appropriate. Intraoperative radiographs of the hip
demonstrated appropriate component position and leg length. The hip
was dislocated and the trial components were removed. An
appropriately-sized acetabular polyethylene component was selected and
cemented into appropriate position, again using tobramycin-impregnated
cement with 4 vials of tobramycin per bag of cement. The acetabular
component was held in appropriate position until the cement had
hardened. After hardening of the cement, the proximal femoral canal
was thoroughly Waterpik'd and dried, and the identical antibiotic
impregnated cement mixture again utilized to cement the coated femoral
component in place. The cement was utilized to provide stable fixation
of the coated component in its proximal 50% to 75%. After hardening of
the cement, trial reduction with a +0 head again yielded satisfactory
length, tension, and stability. An acetabular polyethylene component
had been utilized to accommodate a 40-mm head, and thus a +0, 40-mm
head was applied after cleansing the trunnion and the hip reduced. The
wound was additionally irrigated via pulsing lavage. Abductors were
repaired to the greater trochanter with two #2 PDS sutures through
bone and oversewn with interrupted #1 Biosyn. The split in the vastus
lateralis fascia was closed with interrupted #1 Biosyn. The fascia
lata was closed with interrupted #1 Biosyn, subcutaneous tissue with
interrupted 2-0 Biosyn, and skin with subcuticular 2-0 barbed suture
and overlying Prineo. A sterile dressing was applied. The patient was
returned to the PAR in stable condition.
INDICATIONS: The patient has undergone hybrid left total hip
arthroplasty elsewhere and developed MRSA infection in the
postoperative period. He eventually came to removal of the total hip
arthroplasty components and placement of an antibiotic-impregnated
cement spacer. Subsequent x-rays demonstrated retention of a portion
of the distal cement from the index procedure. He is allergic to
vancomycin, and thus underwent IV treatment with daptomycin in the
postoperative period. He was sent for reimplantation of his left total
hip arthroplasty, but with the retained cement from the index
arthroplasty it was felt that repeat debridement and replacement of
articulating antibiotic-impregnated cement spacers was appropriate.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room
and a satisfactory general anesthetic induced. He was turned onto his
right side and the left hip and lower extremity prepared and draped in
the usual sterile manner. Daptomycin 350 mg IV was administered
preoperatively along with Ancef 2 grams IV. A preoperative timeout was
performed. The index exposure was a posterior approach with the
incision well posterior on the buttock. It was elected proceed with an
anterolateral approach to the hip. A longitudinal lateral incision was
made and dissection carried deeply to fascia. Fascia was divided in
line with the femur distally and at the anterior aspect of the gluteus
maximus proximally. The soft tissues about the hip were thickened,
inflamed, and edematous. The hip was exposed by releasing the anterior
half of the gluteus medius along with the anterior portion of the
vastus lateralis as a sleeve, thus skeletonizing the anterior aspect
of the proximal femur. As the hip was entered, significant amounts of
cloudy, purulent-appearing fluid were encountered. Pseudocapsule and
hypertrophic, purulent-appearing synovium were excised such that the
hip could be dislocated. An off-the-shelf antibiotic-impregnated
cement spacer had been utilized. The proximal cement was removed with
an osteotome and the spacer removed from the femoral canal. The cement
utilized to fix the spacer was easily removed in concert with the
spacer. Purulent-appearing tissue from the bone-cement interface of
the femur was sent for culture. Note that synovial fluid and hip
synovium had been sent for culture. Using cement removal tools, the
retained cement and retained distal cement plug were removed. The
femoral canal was thoroughly debrided with reverse-cutting curettes.
The femur was viewed with image radiographs in multiple planes and
there was no apparent retained cement or foreign material. The canal
was reamed to 16 mm using flexible reamers which provided cortical
chatter over a 4-cm region of the isthmus. The femoral canal was
irrigated with 6 liters of saline via pulsing lavage. The proximal
femur was prepared with reamers and broaches to accommodate a size 10
Stryker EON cemented femoral component and broach, anticipating use of
a smaller femoral component coated with antibiotic-impregnated cement.
Purulent-appearing tissue from about the acetabulum was debrided with
curettes and specimen sent for culture. The cement spacer had eroded
superiorly into the acetabulum. After thorough debridement of the
acetabulum, it was found that there were perforations superomedially,
but the anterior and posterior columns remained intact. The acetabulum
was thoroughly irrigated with 6 liters of saline via pulsing lavage.
Antibiotic-impregnated cement was mixed with 4 vials of tobramycin per
bag of cement. The acetabulum had been prepared with hemispherical
reamers and it was found that 66-mm reamer was necessary to engage
both the anterior and posterior acetabular walls in the correct hip
center position, leaving a defect superiorly. The
antibiotic-impregnated cement was packed into the superior acetabular
defect to act as a spacer. The trial 66-mm acetabular component was
applied and the cement allowed to harden. The remainder of the
antibiotic-impregnated cement was utilized to coat a size 7 Stryker
EON femoral component with a high-offset neck. With the 66-mm
acetabular trial appropriately positioned and the cement augment
having hardened about the superior acetabulum, a trial polyethylene
insert was applied along with a +0 head and the hip reduced. Note that
the size 10 femoral broach remained in place. Length, tension, and
stability appeared appropriate. Intraoperative radiographs of the hip
demonstrated appropriate component position and leg length. The hip
was dislocated and the trial components were removed. An
appropriately-sized acetabular polyethylene component was selected and
cemented into appropriate position, again using tobramycin-impregnated
cement with 4 vials of tobramycin per bag of cement. The acetabular
component was held in appropriate position until the cement had
hardened. After hardening of the cement, the proximal femoral canal
was thoroughly Waterpik'd and dried, and the identical antibiotic
impregnated cement mixture again utilized to cement the coated femoral
component in place. The cement was utilized to provide stable fixation
of the coated component in its proximal 50% to 75%. After hardening of
the cement, trial reduction with a +0 head again yielded satisfactory
length, tension, and stability. An acetabular polyethylene component
had been utilized to accommodate a 40-mm head, and thus a +0, 40-mm
head was applied after cleansing the trunnion and the hip reduced. The
wound was additionally irrigated via pulsing lavage. Abductors were
repaired to the greater trochanter with two #2 PDS sutures through
bone and oversewn with interrupted #1 Biosyn. The split in the vastus
lateralis fascia was closed with interrupted #1 Biosyn. The fascia
lata was closed with interrupted #1 Biosyn, subcutaneous tissue with
interrupted 2-0 Biosyn, and skin with subcuticular 2-0 barbed suture
and overlying Prineo. A sterile dressing was applied. The patient was
returned to the PAR in stable condition.