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Dega Osteotomy

Planning

B

Preoperative Plan

1

Template osteotomy

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

2

Room setup and equipment

  • setup OR with standard operating table
  • c-arm in from contralateral side
  • monitor usually at foot of bed

3

Patient positioning

  • supine
  • slight elevation of involved hemipelvis may be helpful (place "bump" under ipsilateral lumbosacral spine)

Technique

D

Approach

1

Mark the incision (straight "bikini")

  • mark the incision from posterosuperior to anteroinferior to the ASIS
  • the ASIS should be at the midpoint of the incision

2

Determine the internervous plane

  • identify the interval between the sartorius and the tensor fascia latae muscles

3

Identify neurovascular structures

  • identify and protect the lateral femoral cutaneous nerve
  • identify and coagulate the lateral femoral circumflex vessels in the distal portion of the tensor-sartorius interval
E

Deep Dissection

1

Expose the ilium

  • split the iliac apophysis
  • start at the ASIS and extend as far along as possible
  • subperiosteally dissect the TFL laterally to expose the ilium and the full extent of the anterolateral capsule

2

Expose the outer (and usually the inner) tables of the ilium

  • perform subperiosteal dissection to the sciatic notch
  • bleeding from bony nutrient foramen should be controlled
  • place a retractor (like a Chandler) in the sciatic notch from the lateral (and medial) sides to protect the neurovascular structures
  • release the reflected head of the rectus and follow posteriorly
F

Osteotomy

1

Map out the osteotomy

  • insert guidewire starting just cephalad to the AIIS and directed towards the inner wall just above the triradiate cartilage
  • advance the guidewire under fluoroscopy using AP and obturator oblique views
  • the wire will serve as a guide for the level and orientation of the osteotomy

2

Perform the osteotomy

  • starting point will be just above the AIIS
  • plan to leave at least 1-1.5 cm intact bone above the acetabulum
  • starting laterally, use an osteotome to cut the ililum in a medial and inferior direction in line with the guidewire towards the medial end of the triradiate cartilage
  • the posterior third of the ilium should be left intact because it will act as a fulcrum for rotation
  • the less the inner wall is cut, the more the lateral coverage will be with rotation
  • the thinner the roof fragment is the deeper the coverage
G

Mobilization and correction

1

Mobilization

  • Lever the cortex down with a wide osteotome to achieve the desired correction/coverage
  • evaluate correction under fluoroscopy

2

Choose type of graft

  • allograft wedges and autograft wedges from the iliac crest or from a concurrent femoral shortening osteotomy

3

Hold the osteotomy open and stabilize acetabular correction

  • bone graft is usually triangular-shaped
  • size of bone graft is estimated when the osteotomy site is being levered down to achieve desired correction/coverage
  • insert the wedges from a lateral to medial direction
  • it is important to place the largest piece of graft where the most coverage is needed
  • bone graft should be stable when wedged into ilium

4

Evaluate correction with fluoroscopy

5

Assess range of motion

H

Soft Tissue Reattachment

1

Reattach the apophysis

2

Reattach musculature

I

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 or 3-0 vicryl for the subcutaneous tissue
  • use 3-0 monocryl (or comparable suture) for skin

4

Dressings and immobilization

  • apply soft dressing to incision site
  • apply spica cast

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • perform neurovascular exam

2

Order basic imaging studies

  • AP and false profile views

3

Perform operative consent

  • describe complications of surgery including
  • stiffness
  • hip subluxation or dislocation
  • nerve palsy
  • closure of triradiate cartilage
  • chondrolysis
  • AVN of the femoral head
  • infection
  • bleeding
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • IV fluids
  • pain control
  • advance diet as tolerated
  • check appropriate labs
  • wound care

2

Discharge patient appropriately

  • pain meds
  • non weightbearing
  • monitor neurological and vascular status
  • schedule follow up in 6 weeks
M

Intermediate Evaluation and Management

1

Recognize vascular, nerve or other associated injuries

  • document neurovascular status
  • identify if any knee and hip contractures are present

2

Appropriately interprets basic imaging studies and recognizes fracture patterns

  • interpret radiographs of the hip

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: 6 week postoperative visit
  • check radiographs
  • diagnose and management of early complications
  • continue non weightbearing
  • change cast
  • postop: 12 week postoperative visit
  • check radiographs
  • start weightbearing once good radiographic healing has been demonstrated
  • 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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