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Percutaneous Pinning of SCFE

Planning

B

Preoperative Plan

1

Template reduction

  • determine the slip angle and percent displacement

2

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
C

Room Preparation

1

Surgical instrumentation

  • 6.5 or 7.3 mm cannulated screws

2

Room setup and equipment

  • setup OR with standard radiolucent operating table
  • fracture table is an option
  • C-arm in from contralateral side of bed
  • monitor in surgeon direct line of site at foot of bed
  • flex the hip 90 degrees and abduct 45 degrees to obtain lateral views

3

Patient positioning

  • supine
  • pad the ipsilateral arm and position across the chest

Technique

D

Guidewire Placement

1

Identify the course of the guidewire

  • use imaging to identify the femoral neck at its longest
  • internally and externally rotate the hip until the femoral neck appears to be at its longest
  • the femoral neck should be should be horizontal to the operating table and perpendicular to the image beam

2

Align the guidewire

  • place a guidewire on the anterior hip and align the point of the guidewire over the center of the femoral head
  • align the guidewire along the neck
  • mark the skin along the guidewire to identify the planned trajectory of the wire
  • this will represent the trajectory the guide pin should follow on the AP images
E

Determination of the Femoral Neck Entry Point

1

With unstable SCFEs, before manipulation of the leg for lateral views, consider initial temporary fixation of the epiphysis (usually with a guidewire).

2

Determine the path of the bone screw in the sagittal plane

  • flex hip 90 degrees and abduct the hip 45 degrees
  • align the guide wire along the neck over the center of the femoral head
  • this represents the desired path of the screw in the sagittal plane
  • the point that this line crosses the femoral neck is the entry point for the guidewire
F

Skin Entry Site Determination

1

Mark the skin incision

  • example
  • if the slip angle measured is 30 degrees, the entry point on the skin should be 30 degrees from the lateral palpable femoral shaft towards the femoral head

2

Make a skin incision

  • make a 1 cm incision through the skin and spread with the hemostat down to the bone along the line that was previously drawn
  • the point of the guidepin should be positioned on the anterolateral femoral neck where the entry was estimated
  • entry point should be lateral to the intertrochanteric line (on AP view) to avoid screw head impingement
G

Guide Pin Insertion

1

Drill and advance the guidepin

  • drill the guidepin into the midpoint of the femoral neck

2

Check pin placement

  • confirm the position with imaging
  • once the position of the guidepin is confirmed advance the guidepin to within 3 mm of the articular surface and the length is measured
  • should be center center in the EPIPHYSIS

3

Confirm guide pin position

  • confirm the final position of the guidepin with multiple radiographic images
  • must be out of the joint on all images
H

Drilling and Cannulated Screw Placement

1

Measure the length of the cannulated screw

  • measure the guidewire with the cannulated screw depth gauge to determine the desired screw length

2

Place cannulated screw

  • use the cannulated drill over the guidewire
  • stop the drill 1 or 2 mm before the tip of the guidewire
  • drill must cross the physis
  • place a 6.5 mm to a 7.3 mm cannulated screw over the guidewire
  • remove the guidewire
  • single screw fixation is usually favorable
  • compared to multiple screws, lower risk of osteonecrosis and intraarticular penetration
I

Radiographic Evaluation

1

Ensure placement of the cannulated screw

  • use spot AP and frog leg lateral fluoroscopy to ensure placement
  • attempt if possible to have five threads of the screw within the epiphysis to decrease the risk of slip progression

2

Test for penetration into the joint

  • use the "approach and withdraw" method to ensure that the screw tip remains in the femoral head
  • under fluoroscopy range the hip from internal to external rotation at varying degrees of flexion
  • watch to see if the screw tip approaches and withdraws from the subchondral bone
J

Wound Closure

1

Irrigation and hemostasis

  • copiously irrigate the wound

2

Deep closure

  • use 0-vicryl for deep closure

3

Superficial closure

  • use 2-0 vicryl for the subcutaneous tissue
  • use 3-0 monocryl for skin

4

Dressings and immobilization

  • place a soft dressing on the incision

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • screen for risk factors for SCFE including obesity, renal disease, hypothyroidism, growth hormone usage, or prior radiation to the area
  • perform neurovascular exam

2

Order basic imaging studies

  • AP and frog leg lateral hip radiographs
  • Measure slip angle and percent displacement

3

Perform operative consent

  • describe complications of surgery including
  • chondrolysis
  • osteonecrosis
  • further slippage
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • IV fluids
  • DVT prophylaxis
  • pain control
  • advance diet as tolerated
  • check appropriate labs
  • wound care
  • inpatient physical therapy

2

Discharge patient appropriately

  • pain meds
  • touch down weight bearing
  • monitor neurological and vascular status
  • schedule follow up in 2 weeks
M

Intermediate Evaluation and Management

1

Recognize vascular, nerve or other associated injuries

  • document neurovascular status

2

Appropriately interprets basic imaging studies and recognizes fracture patterns

  • interpret radiographs of the hip
  • look for a widened physis on AP or lateral radiographs

3

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

4

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • check radiographs
  • diagnose and management of early complications
  • continue touch down weight bearing
  • postop: 6 week postoperative visit
  • check radiographs
  • start weightbearing
  • check radiographs yearly until skeletal maturity

5

Capable of diagnosis and early management of complications

N

Advanced Evaluation and Management

1

Recognizes factors that could predict difficult reduction and post-operative complication risk

  • abnormal vascular examination
  • neurological deficits

2

Appropriately orders and interprets advanced imaging studies

3

Completes comprehensive pre-operative planning with alternatives

4

Modifies and adjusts post-operative treatment plan as needed

  • recognize deviations from typical postoperative course
O

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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