A Basic Initial Evaluation and Management 1 Obtain focused history and performs focused exam concomitant and associated orthopaedic injuries assess for risk of thromboemblotic disease 2 Orders and interprets required diagnostic studies order and interpret AP pelvis, AP and lateral of the hip 3 Prescribes and manages nonoperative treatment physical therapy Nsaids injections activity modification 4 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit wound check remove sutures check radiographs start resisted abductor exercises at 6 weeks diagnose and management of early complications<br /> postop: ~ 3 month postoperative visit diagnosis and management of late complications<br /> postop: 1 year postoperative visit B Advanced Initial Evaluation and Management 1 Appropriately orders and interprets advanced imaging studies MRI CT nuclear medicine imaging advanced radiographs views 2 Appropriately recommends surgical intervention 3 Modifies and adjusts post-operative treatment plan as needed 4 Provides prophylaxis and manages thromboemblotic disease C Preoperative History and Physical Exam 1 Obtains history and performs basic physical exam perform neurovascular exam check range of motion identify medical co-morbidities that might impact surgical treatment 2 Screen medical studies to identify and contraindications for surgery 3 Order basic imaging studies radiographs AP pelvis AP/Lateral of affected hip 4 Perform operative consent describe complications of surgery including leg length discrepancy infections dislocations thromboembolic dz neurovascular compromise peri-prosthetic fracture deep hip sepsis
E Preoperative Plan 1 P 1 Radiographic Templating Upload AP pelvis film with radiographic marker into the templating software system Identify the radiographic view, side to be templated, and calibrate the image Select the desired acetabular component Determine the preoperative leg length discrepancy attributable to the hip create a line tangential to the base of both acetabular tear drops create a line perpendicular to this from each tear drop to the tip of the lesser trochanter the difference in lengths between these last two measurements is the preoperative leg length discrepancy attributable to the hip Select the appropriate acetabular component, size, and position appropriately Select the desired femoral stem component, size, and position appropriately Select the desired femoral head component Write a summary of the components and their sizes for easy reference during surgery Measure the femoral neck cut determine the distance with a line along the center of the femoral neck axis from the center of the femoral head to the desired position on the femoral component this distance can be measured with a ruler in the operating room to create the desired femoral neck cut Pearls The goal of templating is threefold: 1- estimate the component size; 2- determine the component positioning, especially the femoral neck cut; 3- restore leg length and offset Alternatively the leg length discrepancy can be measured from the longitudinal distance between the ischial tuberosities and the lesser trochanters The component selected should be positioned in order to restore leg length as well as femoral offset 2 Execute Surgical Walkthrough Describe the steps of the procedure to the attending prior to the start of the case Describe potential complications and steps to avoid them F Room Preparation 1 1 Surgical Instrumentation Confirm that all necessary surgical instrumentation is on the back table and sterile 2 Room Setup and Patient Positioning A regular OR table is used The patient is placed in the lateral decubitus position with the operative side up using a pegboard for stabilization place a well-padded axillary roll pegs with appropriate padding are placed posteriorly at the sacrum and lower lumbar spine and anteriorly at the level of the ASIS and lower abdomen ensure the hip can be flexed to 90 degrees to facilitate testing of intraoperative stability A belt is placed around the torso to further stabilize the patient Ensure the down leg and all bony prominences are well-padded A mayo stand is brought in from the head of the bed on the surgeon side A clear polypropylene drape is used to isolate the operative extremity and surgical field prior to surgical prep 3 Surgical Preparation and Draping The mayo stand and arms are covered with two quarter drapes The operative extremity and surgical field is isolated with sterile adhesive impervious drapes A stockinette is placed on the operative extremity above the knee and secured with a self-adhesive wrap An adhesive drape with tails is placed over the impervious drape distally An adhesive bar drape is placed over the impervious drape proximally An extremity drape with side pouches is secured and functions as the upper drape for anesthesia A blue towel with suction, bovie, pulsed lavage, and clamps is opened and secured to the mayo stand, which is now covered by the upper drape An adhesive drape is used to cover all exposed skin on the operative limb 4 Surgical Team Timeout G Posterior Approach to Trochanter 1 P 1 Identify Bony Landmarks Palpate the tip of the greater trochanter Identify the anterior and posterior borders of the femoral shaft Establish the long axis of the femur Pearls In larger patients where palpation of the femur is challenging, the lateral epicondyle at the knee can be used to establish the long axis of the femur. 2 Draw the Planned Incision A curvilinear incision is planned centered over the posterior one third junction of the greater trochanter The incision extends distally along the longitudinal axis of the femur and proximally in line with the fibers of the gluteus maximus 3 Superficial Dissection The skin is incised with a scalpel Sharp subcutaneous dissection in line with the incision is performed using either a scalpel or electrocautery to the level of the fascia retraction of the subcutaneous tissue can create tension and facilitate dissection An elevator or sponge can be used to bluntly dissect the fat at the level of the fascia to further define these two planes Pearls Periodic palpation of the greater trochanter is helpful to guide dissection in the appropriate plane and avoid straying excessively anteriorly or posteriorly. 4 Incise the IT Band Incise the IT band, taking care not to violate the underlying hip abductor muscles Abduct the hip allowing space to bluntly dissect with one's finger under the IT band to define the bursal plane Pearls With a finger in this plane, the IT band can be elevated toward the surgeon to complete the fascial incision proximally and distally. 5 Place Charnley Retractor Split the gluteus maximus in line with its fibers to complete the proximal exposure of the bursal plane Maintaining one's finger in this plane, place the anterior and posterior blades of the self-retaining retractor under the IT band and gluteus maximus muscle Extend the skin incision if there is excessive tension to avoid skin necrosis as well Pearls Ensure that the retractor is not compressing or causing undue traction on the sciatic nerve H Myocapsular Release, Hip Dislocation, and Femoral Neck Cut 1 P 1 Identify the Piriformis and Protect Abductor Mechanism (Gluteus Medius and Minimus) Palpate the piriformis tendon Place a retractor (e.g. double-bend retractor) between the piriformis tendon and the hip abductors Ensure that the retractor is not placed between the gluteus medius and gluteus minimus if so, replace the retractor under the gluteus minimus to ensure the abductors are protected 2 Release Short External Rotator Myocapsular Sleeve Excise the bursal tissue overlying the short external rotators Visualize the piriformis tendon Use the electrocautery to release the piriformis tendon directly off of its bony insertion Tag the piriformis tendon for later identification Release the remaining short external rotators and capsule as a single myocapsular sleeve directly off the bone Once the entire femoral neck can be visualized, carry the capsulotomy proximally, and slightly posteriorly, until the labrum has been released at the level of the acetabulum Pearls Use the electrocautery to release the myocapsular sleeve along the superior border of the piriformis and then along the capsular attachment from superior to inferior. Carry the dissection from proximal to distal until a finger can be placed underneath the femoral neck 3 Dislocate the Hip The assistant on the anterior side of the patient dislocates the hip A combination of flexion, adduction, internal rotation, and inline traction are used in this maneuver 4 Perform the Femoral Neck Cut Identify the level of the neck cut based upon the preoperative template The femoral neck cut is marked at its medial extent and carried to the junction of the superior neck and the greater trochanter An oscillating or reciprocating saw is used to perform the femoral neck cut An osteotome can be used to ensure the cut is complete and a clamp is used to extract the head I Acetabulum: Exposure, Preparation and Component Placement 1 P 1 Expose the Bony Acetabulum An anterior retractor (e.g. double-bend retractor) is placed along the anterior rim of the acetabulum at the 10 or 2 o'clock position depending on the laterality An inferior retractor (e.g. double-bend retractor or a double-pronged inferior retractor) is placed immediately inferior to the transverse acetabular ligament (TAL) at the 6 o'clock position A superior retractor (e.g. ball-spike or sharp hohmann) is placed under the abductor muscles at the 12 o'clock position and malleted into place If necessary, a Gelpi retractor can be placed for additional posterior exposure the anterior tine is placed under the abductors the posterior tine is placed under the capsule to protect the sciatic nerve 2 Prepare the Acetabulum Using a long-handled knife and forceps, the labrum is circumferentially excised The cotyloid fossa is identified and the pulvinar can be removed to expose the floor of the medial wall this aids in assessing the depth of acetabular reaming Circumferential reaming of the acetabulum is performed using sequentially-sized reamers start with a reamer ~4mm smaller than the measured femoral head size sequential reaming by 2mm until peripheral rim fit achieved and bleeding bone visualized this reaming can be done in a neutral position where as the acetabular component will be placed in abduction and anteversion Pearls Initial reaming should insure that the depth is appropriate getting through the medial osteophyte 3 Place Acetabular Components The final reamer is positioned and the desired version is marked along the skin based upon the TAL, anterior, and posterior walls The appropriate sized acetabular component is selected The acetabular component is secured to the appropriate insertion guide and malleted into place ensure appropriate abduction and version, circumferential rim fit, and that the component is fully seated assess component stability and bony purchase acetabular screws can be placed into the ilium for additional fixation if necessary Remove overhanging osteophytes with a curved osteotome and mallet Insert the polyethylene liner Pearls If proper positioning of the acetabular component is uncertain, a trial polyethylene liner can be used and the position verified on radiographs prior to final poly insertion. J Femur: Exposure, Preparation and Trial Placement 1 P 1 Femoral Exposure Flex and internally rotate the femur to visualize the canal Protect the abductors by placing retractor along the greater trochanter Elevate the femoral canal from the wound and visualize the medial calcar using a Mueller retractor 2 Femoral Canal Preparation / Anteversion The assistant rotates the leg so that the tibia is perpendicular to the operating room table this facilitates determination of femoral anteversion A rongeur is used to remove any residual superolateral femoral neck cortical bone A box osteotome is set in appropriate anteversion and advanced with a mallet down the lateral aspect of the femoral canal this sets the version for subsequent broaching A canal finder is advanced manually down the intramedullary femur to guide the angle of subsequent reaming and broaching 3 Perform sequential reaming/broaching A lateralizing reamer is used to avoid broaching in a varus direction Sequentially-sized broaches are inserted with a mallet until a cortical fit is achieved ensure the femoral canal is adequately lateralized and that the broach stems are not placed in varus angulation Pearls The preoperative template assists in determining appropriate sizing Additional reaming may be necessary depending upon the femoral stem being used 4 Place Trial Femoral Head/Neck and Hip Reduction Place the final broach seated to the desired depth with good cortical purchase and rotational stability Place trial femoral neck and head components size and offset are determined by preoperative templating Reduce the hip a skid is placed under the femoral head to guide reduction into the acetabulum the assistant performs the reduction maneuver (traction, external rotation, extension, and abduction) while the surgeon guides the femoral head into place Assess stability and leg lengths manually Obtain intraoperative AP pelvis radiograph Pearls A rongeur or calcar planar can be used to remove any cortical prominences around the broach K Assessing Stability and Leg Length Discrepancy 1 1 Gross Assessment Flex the operative leg to mirror the contralateral "down" leg position Assess discrepancy between legs at the knee and at the heel Excessive joint gapping with shuck test may indicate the leg is short. With the capsule open, approximately 5-8mm of shuck is acceptable. If there is excessive head-cup separation more offset may be necessary. Increasing the offset more than 8mm may make capsular closure difficult and should be avoided Leg lengths should be within 5mm if the leg is too long, decrease the broach size and insert the stem deeper, or, place a shorter femoral head if the leg is too short, increase the broach size and leave the stem more proud or place a longer length head IT band tightness with hip extension and knee flexion may indicate the leg is long 2 Radiographic Assessment Measure difference in heights between the most prominent aspect of lesser trochanters on both legs relative to line tangential to the inferior aspect of both ischial spines or the tear drops L Placement of Final Components 1 P 1 Dislocate the Hip and Remove the Trial Components The surgeon places a bone hook around the inferior femoral neck to guide the head while the assistant dislocates the hip A Mueller retractor is placed to elevate the femoral canal and expose the medial calcar The broach handle is reattached and the broach is removed Pearls The head and neck trials are removed by hand, minimizing potential for compression on the sciatic nerve Attention should be paid to the component anteversion and the depth of insertion as this should be replicated with the final implant 2 Implant Femoral Components Verify that the implant is correct Place the femoral component and impact to the pre-broached depth, ensuring a good fit Inspect the calcar and the peritrochanteric region to ensure that no fracture propagated on insertion Pearls Visualize the femoral canal, retract the abductors, clean the intramedullary canal of all debris especially in the zone of implant fixation/growth 3 Femoral Head Trial and Final Implantation Place the trial femoral head on the trunnion Relocate the hip and repeat stability testing Place the final femoral head component and secure with an impactor and mallet Relocate the hip a final time Pearls If fracture does occur, remove the stem, place circumferential cables along the fracture site, followed by reimplantation of the stem N Wound Closure 1 1 Irrigate the Surgical Site 2 Confirm Hemostasis 3 Perform Posterior Myocapsular Repair Two sutures are passed through the superior and inferior portions of the myocapsular sleeve A drill is used to create two drill holes from the lateral aspect of the greater trochanter and exiting out into the piriformis fossa A suture passer is used to pass both sutures through the corresponding drill hole from deep to superficial The sutures are hand tied over top of the greater trochanter to secure the myocapsular repair Additional sutures are used to repair any gaps as necessary 4 Piriformis Reattachment A new suture is passed through the detached end of the piriformis tendon and then advanced to the undersurface of the hip abductor muscles Tightening the stitch will close the gap between the piriformis and hip abductor muscles 5 Fascial Closure The tensor fascia lata, gluteal fascia, and IT band are re-approximated in a simple interrupted fashion A running barbed suture is used to reinforce the repair 6 Superficial Closure Absorbable sutures are placed in simple interrupted fashion in the subcutaneous layer A running subcuticular absorbable suture is placed Steristrips are applied followed by the desired dressings
O Postoperative Inpatient Management 1 Dictate Operative Report 2 Write admission orders Multimodal Pain Management DVT Prevention Antibiotics & Infection Prevention Wound Care check appropriate labs Activity & Physical Therapy discontinue Foley weight bear as tolerated posterior hip precautions 3 Multi-modal Pain Management 4 Infection Prevention 5 DVT Prevention 6 Medical co-morbidity management and consultation 7 Activity Management 8 Discharges patient appropriately prescribe outpatient physical therapy pain meds DVT prophylaxis schedule follow-up appointment in 2 weeks P Basic Postoperative Outpatient Evaluation and Management Q Advanced Postoperative Outpatient Evaluation and Management R Complex Patient with Complication Evaluation and Management 1 Develops unique, complex post-operative management plans treat infections dislocations neurovascular compromise