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Preoperative Patient Care
Operative Techniques

Preoperative Plan


Template osteotomy


Execute surgical walkthrough

  • describe key steps of the operation verbally to attending prior to beginning of case.
  • describe potential complications and the steps to avoid them

Room Preparation


Surgical instrumentation

  • forked, angled osteotomes


Room setup and equipment

  • setup OR with radiolucent operating table
  • c-arm in from contralateral side
  • Monitor at foot of bed


Patient positioning

  • supine
  • ipsilateral arm abducted on arm board or placed across the chest
  • operative extremity prepped and draped free
  • proximally to costal margin
  • posteriorly to at least the posterior third of the ilium
  • medially to the umbilicus

The Modified Smith Peterson Approach


Mark the incision

  • start the incision 3 cm proximal to the ASIS and extend distally 10 cm
  • the incision should curve medially


Raise subcutaneous flaps


Identify the fascia over the TFL muscle belly

  • incise the fascia in line with the muscle fibers
  • bluntly elevate TFL off intermuscular septum


Reflect the external oblique aponeurosis

  • identify the plane between the external oblique and the gluteus medius and develop it to expose the periosteum over the iliac crest
  • divide periosteum is sharply over the iliac crest and carry subperiosteal dissection out over the inner table of the ilium.

Iliac Spine Osteotomy


Start the iliac spine osteotomy

  • osteotomize the anterior superior iliac spine, preserving the origin of the sartorius and the inguinal ligament
  • incise the periosteum on the medial edge of the iliac crest and reflect medially with the origin of the iliacus muscle
  • elevate direct head of the rectus from the anterior inferior iliac spine and reflect distally (may not be necessary if rectus sparing approach is utilized)
  • leave a stump of the tendon on the AIIS for later repair


Expose the hip capsule

  • psoas sheath is opened longitudinally and the psoas tendon is retracted medially
  • expose the hip capsule anteriorly and inferomedially
  • facilitate exposure by hip flexion and adduction
  • alternatively, the psoas may be retracted by subperiosteal release of its sheath from the pubic ramus and separating the sheath from the capsule in an effort to avoid scarring of the tendon within the sheath

Ischial Osteotomy


Deep dissection for osteotomy

  • interval between the medial joint capsule and the iliopsoas tendon is developed and sequentially dilated
  • use the tip of a long handled Mayo scissor and Lane bone levers, with the tips of each palpating the anterior ischium at the infracotyloid groove and the medial and lateral aspects of the ischium


Place the osteotome through interval between medial hip capsule and psoas tendon

  • place tip in contact with the superior portion of the infracotyloid groove of the anterior ischium just superior to the obturator externus tendon


Check placement with radiographs

  • start the infra-acetabular osteotomy just distal to the inferior lip of the acetabulum and aim towards the middle of the ischial spine


Impact the osteotome

  • osteotome is impacted in a posterior direction 15-20mm deep through first the medial cortex
  • impact the osteotome through the central part of the ischium
  • impact the osteotome to the lateral cortex
  • abduct the leg during this step to protect the sciatic nerve

Pubic, Iliac and Posterior Column Cuts


Facilitate exposure to the pubic ramus

  • flex and adduct the hip to increase the exposure to the hip
  • psoas tendon and medial structures are gently retracted medially


Prepare the pubic ramus cut

  • incise the periosteum along the axis of the superior pubic ramus
  • continue careful circumferential subperiosteal dissection
  • place a pair of narrow curved retractors subperiosteally around the anterior and posterior aspects of the pubic ramus
  • protect the obturator nerve
  • impact a third spike retractor into the superior cortex at least 1 cm medial to the medial most extent of the iliopectineal eminence
  • retract the iliopsoas and the femoral neurovascular bundle medially


Perform the pubic ramus cut

  • orient the pubic cut from anterosuperior and lateral to posteroinferior and medial
  • avoid creating a bony spike in the mobile fragment
  • two options for osteotomy
  • osteotomy can be performed by passing a Gigli saw around the ramus using a Satinsky vascular clamp and sawing upward away from the retractors
  • can also be performed by impacting a straight osteotome just lateral to the spike Hohman


Prepare the iliac cuts

  • release the periosteum on the inner surface of the ilium
  • clear the subperiosteal surface of the ilium and the quadrilateral surface
  • identify the sciatic notch with a large Hohmann retractor


Assess the lateral cortex of the ilium


Protect the abductors

  • A 1.5- to 2-mm subperiosteal window is created beneath the anterior abductors just distal to the ASIS without disturbing the abductor origin
  • narrow, long, spiked Hohmannn retractor is placed in this window and the tip of the Hohman should point toward the apex of the sciatic notch


Make the supra-acetabular cut

  • use the Hohman retractor as a guide, confirm planned level and orientation of the iliac osteotomy with the image intensifier on the lateral projection view
  • make the iliac cut with an oscillating saw in line with the narrow Hohmann retractor, until reaching a point about 1cm above the iliopectineal line (well anterior to the notch)
  • first cut the medial cortex
  • abduct the leg lower extremity to protect the sciatic nerve
  • cut the lateral cortex


Make the posterior column cuts

  • flex and adduct the leg to faciltate retraction of medial structures
  • reverse blunt Hohmann retractor is placed medially with its tip on the ischial spine to expose the posterior column
  • osteotomy is performed through the medial cortex with long straight 1.5cm osteotome
  • osteotomy extends from posterior end of the iliac saw cut, passing over the iliopectineal line, through the medial quadrilateral plate, parallel to the anterior edge of the sciatic notch on the lateral projection of the image intensifier, and is direct toward the ischial spine
  • osteotomy must extend at least 4 cm below the iliopectineal line to avoid entry into the acetabulum when completing the final posteroinferior osteotomy
  • the posterior cut is made first through the medial, then second through the lateral wall of the ischium


Complete the osteotomy of the posterior-inferior corner

  • may be completed directly with an angled chisel or may be completed by indirect fracture through manipulation of the fragment

Mobilization and Correction


Place a Schanz pin in the supra-acetabular region

  • 3.2mm drill hole is made parallel, and just distal to, iliac osteotomy
  • T-handle chuck is used to insert Schanz screw into acetabular fragment, well above the dome of the acetabulum


Test the mobility of the fragment

  • if there is lack of full mobility
  • check the
  • periosteum around the pubic ramus
  • the posterior cortex at the final cut
  • the ischial cut


Perform the correction in the desired plane

  • A 1-inch straight Lambotte chisel is placed into the supra-acetabular iliac saw cut to both confirm completion of the lateral cortex osteotomy and protect the cancellous bone above the acetabulum during displacement
  • A bone spreader is placed into the iliac osteotomy between the posterosuperior intact ilium and the Lambotte chisel anteriorly
  • the tines of a Weber bone clamp are placed onto the superior ramus portion of the aceabular fragment in such a way as to place its handle anterior to, and in contact with, the Schanz screw
  • while gently opening the bone spreader, the Schanz screw and Weber clamp are used to internally rotate the fragment and mobilize the acetabular fragment
  • most common corrective maneuver (to correct anterior and lateral deficiencies)
  • lift the acetabular fragment slightly toward the ceiling, creating initial displacement
  • followed by a three step movement of lateral, distal, and internal rotation



Place provisional fixation

  • place provisional fixation with three or four smooth 2.4 mm K wires


Check correction with radiographs

  • check an AP radiograph of the pelvis that is centered over the symphysis pubis
  • the symphysis pubis should be in line with the saccroccoygeal joint
  • the obturator foramen should be symmetric
  • the pelvis should be horizontal


Evaluate correction with radiographs

  • evaluate the AP radiographs for
  • lateral center edge angle >20 deg
  • acetabular inclination (Tonnis angle) 0-10 deg
  • medial translation of the joint hip center
  • the position of the teardrop
  • the version of the acetabulum


Place final fixation

  • use three or four 3.5 or 4.5 mm cortical screws for final fixation


Confirm final reduction and fixation

  • use imaging to confirm acetabular correction and fixation placement


Assess range of motion

  • hip flexion must be greater than 90 degrees
  • Check for impingement on a lateral project image in 90 deg of flexion
  • assess joint stability by extension, abduction and external rotation

Wound Closure


Remove prominent acetabular fragment

  • trim the prominent acetabular fragment with an oscillating saw
  • use the trimmings to fill the iliac gap


Repair the hip capsule

  • approximate the anterior hip capsule with absorbable suture if capsulotomy was performed


Reattach soft tissue attachments

  • repair the rectus tendon origin with nonabsorbable suture
  • reposition and fix the ASIS fragment with nonabsorbable suture with drill holes in the ilium


Deep closure

  • repair oblique fascia to the abductor fascia over the iliac crest


Superficial closure

  • use 3-0 vicryl for subcutaneous tissue
  • use 3-0 monocryl for skin
Postoperative Patient Care
Private Note

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