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Preoperative Patient Care
Operative Techniques

Preoperative Plan


Template reduction

  • determine the slip angle and percent displacement


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

  • 6.5 or 7.3 mm cannulated screws


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


Patient positioning

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

Guidewire Placement


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


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

Determination of the Femoral Neck Entry Point


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


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

Skin Entry Site Determination


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


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

Guide Pin Insertion


Drill and advance the guidepin

  • drill the guidepin into the midpoint of the femoral neck


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


Confirm guide pin position

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

Drilling and Cannulated Screw Placement


Measure the length of the cannulated screw

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


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

Radiographic Evaluation


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


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

Wound Closure


Irrigation and hemostasis

  • copiously irrigate the wound


Deep closure

  • use 0-vicryl for deep closure


Superficial closure

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


Dressings and immobilization

  • place a soft dressing on the incision
Postoperative Patient Care
Private Note

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