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Preoperative Patient Care
Operative Techniques

Preoperative Plan


Template dislocation


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

  • 3.5 or 4.5 cannulated or non-cannulated screws
  • osteotomy templates
  • osteotomes
  • burr with round tip


Room setup and equipment

  • setup OR with standard operating table
  • peg board or lateral hip positioner
  • C-arm in from contralateral side
  • monitor in surgeon direct line of site at foot of bed
  • flex the hip 90 degrees and abduct 45 degrees to obtain lateral views
  • check patient range of motion BEFORE turning lateral


Patient positioning

  • full lateral with a peg board or hip positioner

Approach to the Hip Capsule


Mark and make the incision

  • center the incision over the junction between the anterior and middle thirds of the greater trochanter
  • make straight, longitudinal skin incision in line with femur
  • split the fascia lata distally in line with the incision
  • continue the proximal dissection through the interval between the anterior edge of the of the gluteus maximus and the tensor OR split gluteus maximus
  • incise the most proximal 4 to 5 cm of the vastus lateralis just anterior to gluetus maximus tendon
  • elevate the vastus muscle anteriorly, staying extra-periosteal


Find and develop interval between piriformis and gluteus medius

  • identify capsule deep to gluteus medius
  • leave the gluteus minimus connected to the gluteus maximus


Perform trochanteric osteotomy

  • extends from superoposterior corner of trochanter to vastus ridge
  • should be approximately 15mm thick
  • leave the piriformis tendon and the short external rotators intact on the remaining base of the greater trochanter
  • reflect the trochanteric flip piece anteriorly along with its muscle attachments


Expose the hip capsule

  • elevate the capsular minimus anteriorly
  • dissect the interval between posterior edge of the capsular minimus and the piriformis tendon
  • expose the capsule up to the rim of the acetabulum both superiorly and anteriorly

Hip Arthrotomy


Perform capsulotomy

  • make a Z shaped capsulotomy with the longitudinal arm of the Z in line with the anterior neck of the femur
  • first cut in line with the inferior femoral neck extending proximally to labrum
  • extend the distal arm of the capsulotomy anteriorly and remain proximal to the lesser trochanter
  • extend the proximal arm posteriorly along the acetabular rim just distal to the labrum and proximal to the retinacular branches of the medial femoral circumflex artery



Test for areas of impingement

  • bring the hip through a full range of motion to test for areas of impingement


Dislocate the hip

  • place the leg in the sterile side bag
  • flex, externally rotate and adduct the hip while the hip is subluxated anteriorly through the arthrotomy
  • place a bone hook anteriorly on the femoral neck to assist in subluxation of the hip
  • divide the ligamentum teres using curved meniscus scissors to allow full dislocation of the hip

Dynamic Assessment


dynamic assessment

  • check the entire femoral head and acetabulum for chondral flaps/tears or labral tears



Resect aspherical segment of the femoral head while respecting blood supply to femoral head

  • use a quarter inch osteotome and rongeur to resect aspherical segments at the head-neck junction
  • use burr to smooth head-neck junction


Reassess the hip

  • reduce the hip and assess the results of the osteoplasty by taking the hip through a full range of motion
  • look for impingement and/or instability


Confirm re-establishment of the femoral head-neck offset radiographically

  • take AP and lateral of the hip with the hip in 90 degrees of flexion

Osteotomy Fixation


Reduce the trochanteric flip piece

  • use towel clamp to control the fragment and a ball-spike to maintain reduction


Secure the trochanteric wafer

  • use two-three 3.5 mm or 4.5 mm screws to secure the trochanteric flip piece


Confirm the reduction with fluoroscopy


Wound Closure


Irrigation and hemostasis

  • copiously irrigate the wound


Close the capsulotomy

  • perform repair of the capsulotomy


Repair soft tissues

  • close the fascia of the vastus lateralis with absorbable running suture


Deep closure

  • close tensor fascia and gluteal fascia


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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