A Outpatient Evaluation and Management 1 Obtain focused history and performs focused exam history: past history of cancer or radiation, prior treatments pre-existing pain smoking or chemical exposure constitutional symptoms fever physical exam notes lymph node involvement, lumps/nodules 2 Interprets basic imaging studies describe the radiographic appearance osteolytic osteoblastic 3 Prescribes and manages nonoperative treatment understand when to have the patient back to clinic for follow-up understand when to order new radiographic imaging studies 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 check radiographs start formal physical therapy diagnose and management of early complications<br /> infection DVT/PE wound breakdown neurovascular compromise hardware failure postop: 4-6 week postoperative visit check radiographs diagnosis and management of late complications<br /> postop: 1 year postoperative visit B Advanced Evaluation and Management 1 Appropriately orders and interprets advanced imaging studies/lab studies 3D radiographic studies to include CT MRI lab studies SPEP/UPEP PSA other tumor markers 2 Recommends complex non-operative treatment RFA or cryoablation Bisphosphonates Kyphoplasty or vertebroplasty 3 Nonoperative treatment infection wound breakdown DVT/PE) 4 Pre-operative preparation and consultation onc rad onc counseling C Preoperative H & P 1 Obtains history and performs basic physical exam history pain and function past medical/surgical/social/family history review of systems physical exam heart lungs extremity exam range of motion strength sensation skin changes tenderness screen medical studies to identify and contraindications for surgery 2 Orders basic imaging studies radiographs AP/lateral of the lesion Joint above and below the lesion 3 Prescribe non-operative treatment protected weightbearing bracing no intervention 4 Perform operative consent describe complications of surgery including Infection Wound complications Neurovascular compromise Tumor progression DVT/PE Pneumonia
E Preoperative Plan 1 Template instrumentation bipolar hemiarthroplasty system 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 Surgical instrumentation hip cemented hemiarthroplasty system 2 Room setup and equipment standard OR table sterile hoods with circulating fans for surgical team hip positioners or bean bag check back table to make sure correct equipment available 3 Patient positioning lateral decubitus with operative extremity facing up axillary roll, anterior positioner on pubic symphysis, posterior positioner on sacrum, Foley in place in obese patients place towel or pad between positioners and skin check to make sure operative leg can be flexed to 90° with positioners in place arms stacked on top of each other with blankets underneath and in between, taped down to arm boards prep and drape entire leg above iliac crest and midline sacrum to make sure adequate working area bovie pad on contralateral thigh or abdomen foot in "candycane holder" and ankle stirrup with extremity externally rotated to prevent knee buckling during prep G Posterolateral Approach to the Hip 1 Mark out GT and anterior/posterior borders of femur and anterior bow of femur mark out the anatomy of GT 2 Mark incision posterior to midline of GT down shaft of femur incision is curved posterior to edge of GT, aimed towards PSIS proximally 1/3 of incision proximal to GT, 2/3 distal to GT (~10-15cm long) 3 Perform skin incision use 10 blade for skin incision curve incision posterior aiming for posterolateral corner of GT incise fascia 2-3 cm with knife just posterior to midline of GT 4 Expose the fascia lata insert 2 self retainers (Wheatlanders, Oberhills for larger patients) at 1/3 and 2/3 aspect of incision cauterize bleeders in subcutaneous tissue use knife down to fascia lata 5 Develop fascial plane use Cobb and dry lap to sweep soft tissue abduct leg 30° to relax TFL place Hibbs retractor proximally 6 Incise fascia 2-3cm with knife just posterior to midline of GT start distal and move proximal with cautery H Deep Dissection of Posterior Approach to the Hip 1 Place Charnley retractor anterior long blade, short blade posterior retract glut medius and minimus anteriorly while just glut max posterior use Charnley retractor.Split the glut max. Tag SERs with 5 ethibond. 2 Split glut max perform blunt dissection using index fingers in center of decussating fibers this will expose trochanteric bursa on lateral margin of GT 3 Dissect the SERs abduct leg until short external rotators (SERs) are visualized internally rotate hip to place SERs on stretch incise soft tissue and bursa off of posterior aspect of GT with leg extended this will keep the sciatic nerve out of field identify SERs (piriformis and obturator internus, gamelli) and quadratus distally (can often feel piriformis tendon proximally) start distally just proximal to quadratus and move proximally extend proximally along posterior aspect of abductors, extend distally until quadratus femoris (will bleed due to medial femoral circumflex artery) locate the sciatic nerve in fat deep to piriformis and superficial and posterior to SERs 4 Tag SERs place #5 Ethibond tag sutures (x3) into SERs and anterior capsule place hemostat on each pair grab enough soft tissue for repair later on 5 Release remaining capsule using longitudinal or T-shaped incision 6 Dislocate hip via flexion, adduction and internal rotation (leg perpendicular to ground, 90-90°) I Femoral Head Extraction 1 Make preliminary neck cut with sagital saw to get more room to remove femoral head 2 Remove femoral head via corkscrew or ring shaped tenaculum cauterize soft tissue away and clean off with Cobb 3 Use native femoral head to measure size for templating implant head size (typically 46-52mm J Canal Preparation 1 Elevate the femur use proximal femoral retractor (double prong, equal prongs on either side) and place under GT to help elevate femur and protect soft tissues can use Hibbs or #1 acetabular retractor to get better calcar exposure 2 Make the femoral cut make neck cut 0.5-1cm proximal to lesser trochanter start with the box cutter , then canal finder then lateralizing reamer to make sure you are down canal and not in varus 3 Broach up sizes from small to larger start at 10, then 11, 12 (typically 12-13 size stem final) want snug fit but don’t need to overtighten cement will fill void between implant and bone need to hit broaches with same power to evaluate if it’s advancing 4 Check calcar for any evidence of fracture place leg in extension and internal rotation to visualize the calcar 5 Trial implants start extending leg and hyper internal rotation to get max exposure of proximal femur, then femoral head place implants 6 Relocate the hip 7 Check for stability, range of motion and leg lengths K Cement Insertion 1 Dislocate hip, remove trials, size and place cement restrictor (typically 11-12mm) place cement restrictor 15cm down from neck cut (length may vary depending on stem being used) 2 Clean and dry canal using epinephrine soaked sponge suction out canal 3 Insert cement in retrograde fashion pressurized with gun place sponge in acetabulum to block cement extrusion cement typically takes 3.5-4.5min to reach appropriate consistency for insertion 4 Cover tip of stem with extra cement L Final Implants 1 Use stem pusher and Tommy bar to control depth and anteversion place in 10-15° anteversion (angled posterior for increased anteversion) add 5-10° if worried about posterior dislocation hold in place until cement hard (~15min) 2 Trial head and neck size (typically +7, +10.5) engage Morse taper, allow cement to dry, and relocate hip 3 Confirm Implant Position and Extremity check final anteversion of stem and impingement, leg lengths, rotation when hip dislocates anterior and posterior N Wound Closure 1 Irrigation, hemostasis, and drain pulsatile irrigate acetabulum and deep tissues cauterize peripheral bleeding vessels 2 Deep closure repair short external rotators and capsular layer with #5 Ethibond figure of 8 sutures tie to either glut medius anteriorly or through bone on posterior aspect of GT close TFL with #1 Ethibond figure of 8 sutures 3 Superficial closure use 3-0 vicryl for subcutaneous tissue use 3-0 nylon for skin 4 Dressing and immediate immobilization soft incision dressings over hip
O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care remove dressings POD 2 appropriately orders and interprets basic imaging studies post-op xrays of hip to evaluate cement mantle and stem position appropriate medical management and medical consultation inpatient physical therapy start range of motion exercises of the hip and knee weight bear as tolerated posterior hip precautions 2 Discharges patient appropriately pain meds outpatient PT schedule follow up appointment in 2 weeks wound care R Complex Patient Care 1 Recommends appropriate biopsy including biopsy alternatives and appropriate techniques understand role of open biopsy vs needle biopsy 2 Develops unique, complex post-operative management plans 3 Discusses prognosis and end of life care with patient and family