Implant in US
HOLY CROSS HOSPITAL
4725 NORTHFEDERAL
HIGHWAY
FORTLAUDERDALE,
FLORIDA
33308
Under the direction of The Sisters of Mercy
(954) 771-8000
PATIENT:
ACCOUNT:
HOOOI 4296808
DATE OF BIRTH:
AGE:
60
DATE OF ADMISSION:
07/06/11
MR NUMBER:
MOO2171372
Age at implant
ATTENDING PHYSICIAN: LEONE,WILLIAM A
ADMITTING PHYSICIAN: LEONE,WILLlAM A
SEX:
Female
(OR)
(OR)
date of implant
OPERATIVE REPORT:
DATE OF SURGERY: JULY 6,2011
not a revision stem
SURGEON: LEONE, WILLIAM A MD
ASSISTANT: S. SIMONTON: PA
ANESTHESIOLOGIST: P. RODRIGUEZ, M. D./CRNA.
ANESTHESIA: SPINAL
PREOPERATIVE DIAGNOSIS: DEGENERATIVE OSTEOARTHRITIS RIGHT HIP
Stryker Rejuvenate
not a revision stem
POSTOPERATIVE DIAGNOSIS: DEGENERATIVEOSTEOARTHRITIS RIGHT HIP
OPERATION: RIGHT TOTAL HIP REPLACEMENT (Stryker Trident PSL size E 50 mm acetabular
component, X-3 neutral liner for a 36 ballla Stryker Rejuvenate SPT size 7 femoral stem, 34 mm modular
neck set for 127 degrees neck angle and neutroversion, V 40 taper, +2.5 neck length, Delta ceramic
36 mm ball).
JUSTIFICATION: Painiul knee disease: which is not responsive to conservative care. The patient will
undergo total hip replacement with the hope of relieving discomfort, allowing pain free walking, correction of
deformty and resumption of a more independent lifestyle in our community.
DESCRIPTION OF PROCEDURE.
is placed supine on an operative table. Anesthesia
is administered and a Foley is inserted. The patient is turned into a lateral decubitus position. The position
maintained with a beanbag supported by kidney rest. An axillary roll is placed. All bony prominences
carefully padded. The hip r q i o n is scrubbed, prepped and draped in the usual sterile fashion.
A pelvic alignment pin is placed in the superior anterior iliac crest. A curvilinear incision is positioned over
the lateral aspect of the greater trochanter. This incision carried to the level of deep fascia. Small bleeders
found fulgurated. Underlying deep fascia incised the length of this incision. Fibers of the gluteus maximus
are divided through the muscles mid substance using blunt dissection The hip joint capsule is arthrotomized
at the posterior base of the femora neck and then T d proximally. Capsular attachments are released
superiorly as %wellas inferiorly to midline: but preserved for later repair. Gently the hip is dislocated posteriorly
afler leg length and offset measurements taken. The femora neck is osteotomized at the appropriate level
for a Rejuvenate hip stem. The head neck fragment removed. The femoral head appeared grossly
Report #: 0706-0100
Location: HC4WE
Operative Note
Page 1 of 3
Patient Type: DIS IN
NAME:
MR NUMBER: M002171372
ACCOUNT NUMBER:
HOOOI4296808
degenerated. The superior aspect was flattened. There is exposed subchondral bone which appeared
sclerotic or eburnated. Evidence of cystification and peripheral spurring. Similar changes on the acetabular
side with remarkable synovitis with effusion. The tissue seemed quite friable and there was more bleeding
than I would normally expect to see. Attention is now turned to the acetabulum.
A series of Steinmann pins are placed into the ischium as well as the ileum, which act as self-retaining
retractors. Gently the proximal femur is translocated anteriorly to gain exposure of the acetabulum. The
labrum is excised while preserving the capsule. Remaining soft tissue or cariilage within the acetabulum is
also removed using a small spherical reamer as well as a hand curet. Cystic lesions are debrided. The
acetabulum is reamed and prepared for a Press-Fit acetabular component. I choose a Stryker PSL Trident
E 50 mm acetabular component. I impact this component in what appeared to be 45 degrees of abduction
and 20 degrees of anteversion. I achieved an excellent Press-Ft. I digitally evaluated this. There vms no
motion. I felt this obviated the need or inherent danger in adding additional screws to augment this fixation.
A central metal dome plug is now placed followed by a neutral X 3 liner. Attention nov, turned to the femur.
The medullary canal is now entered through the sawn off femoral neck Mth a starter reamer: lateralizing into
the greater trochanter. The proximal femur is reamed and broached for a Rejuvenate femoral component.
The size 7 broach is placed to the proposed level. The broach is placed in what appeared to be 15 degrees
of anteversion. I preformed a trial reduction with a 34 mm modular neck set for 127 degrees neck angle and
neutroversion with a +2.5 neck length 36 ball. Soft tissue tension appropriately re-established and the
stability range produced superb. Clinically I re-measure leg length. I am on the mark. I specifically palpate
posteriorly in the r q i o n of the sciatic nerve. There was no tension on the nerve %i,!iththe limb in extension or
various degrees of flexion. The trial components are dislocated.
Product ID
The Rejuvenate broach is removed. I implant a Stryker Rejuvenate size 7 non-cemented hip stem in what
appeared to be 15 degrees of anteversion. The stem was fully seated. There was no indication of fracture.
I impact the modular neck 34 mm set for 127 degrees neck angle and neutroversion. A trial reduction was
again performed. It was my impressionthat soft tissue tension appropriate and stability range produced
superb. The trial head was removed, the taper cleaned and dried. I impact a +2.5 neck length, V 40 taper,
Delta ceramic 36 mm ball. The hip is reduced.
Product ID
The wound is copiously irrigated. A thorough search is made for small bleeders or retained instruments.
None found. A single arm of a Davol drain placed deep within the hip. The sciatic nerve is now visualized
This allows more confident and secure repair of the hip joint capsule and short external rotators in layers
using #2 Ethibond suture. This also allows further confirmation that the sciatic nerve is not under tension
and has not been injured in any way. Tissues are locally infiltrated with Marcaine 0.25% wth epinephrine
and morphine sulfate. Deep fascia closed in an interrupted fashion also with 1-0 Vicryl, proximally in two
layers. The subcutaneous tissue in layers with 2 4 Vicryl and the skin with a running 3-0 Prolene SteriStrips placed on top of the wound followed by a sterile dressing.
The prmedure was tolerated Mthout difficulty and they were returned to the recovery room stable
Report #: 0706-0100
Location: HC4WE
Operative Note
Page 2 of 3
Patient Type: DIS IN
NAME:
MR NUMBER: MOO2171372
ACCOUNT NUMBER:
HOOOI4296808
I
LEONE, WILLIAM A MD
Date
Signed
Time
Signed
<Electronically signed by WILLIAM A LEONE MD>
Date of Electronic Signature 07/13/11 1545
cc:
Date of Dictation: 07/06111 0846
Date of Transcription: 07/06/11 1110
Transcriptionist: ERG
Report #: 0706-0100
Location: HC4WE
Operative Note
Page 3 of 3
Patient Type: DIS IN
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Acct#H00014296808
@Holy Cross
Hospital
07/06/11
3
MR#M002171372 06/27/1951 59 FC HM
4725 North Federal Highway
Fort Lauderdale, Florida 33308
(954) 771 -8000
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Revision in US
HOLY CROSS HOSPITAL
4725 NORTHFEDERAL
HIGHWAY
FORTLAUDERDALE,
FLORIDA
33308
(954) 771-8000
Under the direction of The Sisters of Mercy
PATIENT:
ACCOUNT:
H00017252046
MR NUMBER:
MOO2171372
DATE OF BIRTH:
AGE:
61
SEX:
Female
DATE OF ADMISSION:
03/20/13
ATTENDING PHYSICIAN: LEONE,WILLIAM A
ADMITTING PHYSICIAN: LEONE,WILLIAM A
(OR)
(OR)
Revision 623 days after implant on
7/6/11
OPERATIVE REPORT
No trauma, dislocation or infection;
Revision=failed hip implant; no device fracture
DATE OF OPERATION: March 20, 2013
PREOPERATIVE DIAGNOSIS: Failed right total hip replacement with Modular Rejuvenate hip stem.
POSTOPERATIVE DIAGNOSIS: Failed right total hip replacement with Modular Rejuvenate hip stem.
OPERATION PERFORMED: Revision right total hip replacement (Stryker Orthopedics Exeter size 2, 44
mm offset femoral component, +2.5 neck length, V40 taper, delta ceramic 36 ball, size E neutral X3
polyethylene insert for 36 mm ball impacted into stable size E Trident acetabular shell).
replacement stem
SURGEON: WILLIAM A. LEONE, MD
ASSISTANT: TAMARA HUDAK, PA
ANESTHESIA: General.
elevated systemic cobalt level with
symptomatology and MRI findings with
abnormal fluid collection
ANESTHESIOLOGIST: Edward Ferrer, MD
INDICATIONS: The patient is a 61-year-old lady, who underwent right total hip replacement over 2 years
ago. She was reconstructed with a Modular Rejuvenate hip stem. Unfortunately, studies have revealed
an elevated systemic cobalt level with symptomatology and some concerning MRI findings with abnormal
fluid collection. She has been counseled regarding hopeful benefits as well as risk of further revision
surgery. The hope of surgery importantly will be to place stable components recreating hip mechanics all
with the hope of allowing her to walk pain free and resume a very active and independent and pain free
life in our community. The hope also is that with time the abnormal systemic cobalt levels will normalize
and any abnormal local tissue reaction also will be stopped and surrounding tissue preserved to the best
of our ability.
PROCEDURE IN DETAIL: The patient was placed supine on the operating room table. She was
intubated receiving general anesthesia under the care of Dr. Ferrer. A Foley was inserted. She was
turned into a right lateral decubitus position, and this position iwms maintained with a bean bag supported
by a kidney rest. An axillary role was placed. Bony prominences were carefully padded. The right hip
region was scrubbed, prepped and draped in the usual sterile fashion, but for an extensile approach as
indicated. A pelvic alignment pin was placed superoanterior ileum. I resected the scar overlying the
posterolateral lefl hip from prior surgery, but will extend this incision both proximally as iwell as distally for
Report #: 0320-0178
Location: HC4WE
Operative Note
Page 1 of 3
Patient Type: DIS IN
gross black, flaky
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1 Spccirnen Informatian
Patierit Informatian
AGE: 61
Gender:
F
Pliorlr:
305.651 3246
Patient ID:NG
11:06:21 AM
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Client #: 19902
S&fONTON7SUSAN
HOLY CROSS MEDICAL ORTHOP
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5597 N DIXIE WWY FL 2
OAKLAND PARK,FL 33334-3406
elevated cobalt and
chromium
09/05/2013 THU 11:43
0096/108
FAX
11/2/2010 9;41 AM
Spectrum / Elite —>
Page
Aventura
2999 NE 191 Street Suite 103
Aventura FL 331R0
Phone: 305-692-2222
Fax: 305-692.-2233
1, Ice 14:3'1
To: LULSA SZTERN,MI)
Name:
MRN AVT)007073
Phone:
6
BOB:
Exam Start: 10/30/1() 2:34 pm
Fax: 305-944-2724
Exam:.
CPT Codcfo):
Clinical:
1 of 2
MRT of the Hip
73721
HISTORY: 59 year-old with hip pain, suspected internal drainage.
TECHNIQUE: MRI of the right hip was performed at 3 Testa field strength. Corona! T1 and fast IR,
axial fast T2 images across both hip joints were obtained, followed by small field-of-view corona!
T1. and T2 and sagittal fast T2 images of the right hip joint.
FINDINGS:
Images across both hip joints show normal marrow signal In the femoral head and
neck arid IntertrochanterIc area and in the visualized segment of the dlaphyses bilaterally, except
small areas around the fovea on the right with signal increase on Fat-suppressed images. Around
the acetabuium areas of signal increase are seen at the anterosuperior aspect in the subarticular
marrow bilaterally. On both sides of symphysis pubis signal increase is seen, more on the left.
The small field-of-view images of the right hip show evidence of advanced articular cartilage loss
with fluid intensity seen in the narrowed joint space at weight-bearing area over the Femoral head
and the acetabular articular surface. The cortex is irregular where subchondral marrow signal
changes In the acetabuium are seen. Bony margin shows irregularity and some remodeling in the
acetabuium and there is a subtle lateral shift of the femoral head. There Is Increased joint fluid
and there is thickening of the synovium noted outlined by the joint fluid in the right hip joint. The
capsule is distended.
The periarticufar musculotendinous structures show no focal disruption on the right. Images
across the midlirie show abnormal fluid Intensity signal increase around the insertion of the gluteus
mlnimus tendon with lesser degree of similar changes on the right.
IM PRESSION:
1. MRI of the right hip shows osteoarthrotic changes with advanced articular cartilage loss
in the weight-bearing area in the femoral head and in the acetabuium, where erosive
marrow reaction is seen at the anterosuperior aspect In the subchondral bone. The bony
acetabular margin is irregular and the fibrocartliaginaus tabrum irregular or absent In
the anterior and superior sector.
2. There is a joint effusion and thickened synovlum with distention of the joint capsule on
the right suggesting chronic synovitis.
3. There Is no evidence of stress reaction, occult fracture, osteonecrosls or multifocal
marrow replacement.
4. No evidence of recent musculotendinous or ligamentous disruption Is seen. There Is
tendinotic signal increase in the gluteus minirnus tendon bilaterally, with the chafes
more advanced on the left.
noted: 11.2'2010 9:41 ntn
(Exam 64,1004)
Page 1 of2
2097/108
09/05/2013 THU 11:43
FAX
11/2/2010 9:41 AM
Spectrum / Elite -)
Page
2 of 2
(to/
(Exam 644004)
MRNMAVE007(173
5. Correlation with conventional radiographs of the right hip joint is suggested In the
evaluation of bony details of the degenerative changes.
6. Incidentally,
at
the
symphysis
pubis
degenerative
erosive
and
changes
with
osteophytosis is seen and also in the left hip joint, of lesser degree than seen on the
right.
Interpreting Radiologist
Kalevi Soila, Mll C:AQ Neuroradiology
Diplomate, American Board ofRadiology
Electronically Signed: 11/2/10 9:41 ntu
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