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Septic Hip Irrigation and Debridement

Planning

B

Preoperative Plan

1

Radiographic discussion

2

Execute a surgical walkthrough

  • describe steps of the procedure to the attending prior to the start of the case
  • describe potential anatomic dangers of procedure and steps to avoid them.
C

Room Preparation

1

Surgical instrumentation

  • deep right angle retractors and a Cobb elevator
  • drain or penrose catheter

2

Room setup and equipment

  • standard OR table

3

Patient positioning

4

test

  • supine
  • place a bump under the ipsilateral hip to elevate it 25 degrees

Technique

D

Anterior Approach

1

Mark the anterior incision

  • flex the hip 90 degrees to develop the crease
  • draw a line that is in line with the skin crease of the anterior hip
  • the incision should be 2cm medial and 2 cm lateral to the ASIS

2

Perform dissection

  • perform sharp dissection through the skin and subcutaneous tissue
  • externally rotate the leg and identify the sartorius
  • identify the interval between the sartorius and tensor fascia lata
  • open the interval using use Metzenbaum scissors, small blunt retractors, or a hemostat
E

Joint Capsule Exposure

1

Identify neurovascular structures

  • identify the lateral femoral cutaneous nerve beneath the fascia on the lateral border of the sartorius
  • retract the nerve medially
  • look for the lateral femoral circumflex vessel branches at the distal portion of the interval.
  • these branches may be coagulated without increasing risk of osteonecrosis to the femoral head
  • identify the direct head of rectus femoris tendon tendon
  • the direct head inserts onto the AIIS
  • identify the indirect head
  • at the proximal extent of the direct head lies the indirect head
  • this will divide and travel out laterally to insert at the junction between the acetabulum and the hip joint capsule

2

Expose the joint capsule

  • use a Cobb elevator for blunt dissection to expose this deeper layer
  • retract the head of the rectus femoris muscle medially
  • this exposes the capsular iliacus and deep capsule of the hip joint
  • use a cobb or peanut retractor and remove any remaining soft tissue from the capsule
F

Arthrotomy

1

Create arthrotomy window

  • use sharp dissection to remove a square window of capsule
  • window can vary in size but typically 1 to 2 cm
G

Cultures

1

Take aerobic and anaerobic cultures

  • include two samples for Gram stain and cell count
H

Irrigation and Stability Assessment

1

Copious irrigate the hip joint

  • irrigate the joint until all purulent material has been removed

2

Check the stability of the joint

  • assess the stability of the joint by placing the hip in extreme positions of abduction and extension
I

Drain Placement and Wound Closure

1

Place penrose drain

2

Close superficial layers with absorbable suture

3

Place soft dressings

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • check range of motion

2

Screen medical studies to identify and contraindications for surgery

3

Orders appropriate initial imaging and laboratory studies

  • radiographs, CRP,ESR and WBC count

4

Perform operative consent

  • describe complications of surgery including
  • delay in diagnosis
  • osteonecrosis
  • damage to the LFCN
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • advance diet as tolerated
  • IV fluids
  • inpatient occupational and physical therapy
  • weight bear as tolerated
  • IV antibiotics
  • pain control
  • wound management
  • remove dressings POD2
  • check appropriate labs
  • WBC, ESR and CRP

2

Appropriate medical management and medical consultation

  • consult infectious disease

3

Discharges patient appropriately

  • pain control
  • oral antibiotics
  • schedule follow up in 2 weeks
  • wound care
M

Intermediate Evaluation and Management

1

Obtains focused history and physical, recognizes findings commonly associated with hip septic arthritis

  • history
  • similar to history of osteomyelitis
  • vaccination history must be obtained
  • symptoms
  • presents more acutely than osteomyelitis
  • often associated with fever and other systemic symptoms causing toxic appearance
  • children refuse to walk or move their hip
  • physical exam
  • inspection and palpation
  • localized swelling
  • effusion, tenderness, and warmth
  • hip rests in a position of flexion, abduction, and external rotation
  • hip capsular volume is maximized with flexion, abduction, and external rotation and is the position of comfort for hip septic arthritis
  • range of motion
  • severe pain with passive motion
  • unwillingness to move joint (pseudoparalysis)
  • examine adjacent joints
  • must rule out adjacent joint involvement
  • recognizes factors that could predict complications or poor outcome

2

Orders and interprets required diagnostic studies

  • radiographs
  • AP and frog-leg lateral pelvic x-rays
  • ultrasound
  • may be helpful to identify effusion
  • can be used to guide aspiration
  • MRI
  • difficult to obtain emergently
  • identifies a joint effusion and adjacent osseous involvement
  • must distinguish from transient synovitis
  • 90% chance of septic arthritis if 3 out of 4 of the following are present
  • WBC > 12,000 cells/µl
  • inability to bear weight
  • fever > 101.3° F (38.5° C)
  • ESR > 40 mm/h
  • CRP > 2.0 (mg/dl)
  • temperature > 101.3° (38.5° C) is the best predictor of septic arthritis followed by CRP of >2.0 (mg/dl)
  • hip aspiration

3

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

4

Postop: 2-3 Week Postoperative Visit

  • wound check
  • diagnose and management of early complications
N

Advance Evaluation and Management

1

Assimilates all diagnostic testing and makes a decision about the need for surgical drainage

2

Modifies post-operative plan based on response to treatment

  • patient fails to improve post-operatively
O

Complex Patient Care

1

Modifies post-operative plan based on response to treatment

  • patient fails to improve post-operatively

2

Able to develop a comprehensive preoperative plan that includes options based on intraoperative findings

  • managing dislocated hip
 

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