Preoperative Patient Care A Intermediate Evaluation and Management 1 Recognize vascular, nerve or other associated injuries document neurovascular status 2 Appropriately interprets basic imaging studies and recognizes dislocation or subluxation interpret radiographs of the hip; evaluates acetabulum 3 Makes informed decision to proceed with operative treatment describes indications and contraindications for surgical intervention 4 Provides post-operative management and rehabilitation postop: 1- 2 week postoperative visit check radiographs diagnosis and management of early complications postop: 6 weeks postoperative visit check radiographs remove cast start physical therapy post-op: 3 months postoperative visit check radiographs and range of motion 5 Check radiographs every 1-2 years(until near skeletal maturity) 6 Capable of diagnosis and early management of complications cast problems B Advanced Evaluation and Management 1 Recognizes factors that could predict difficult reduction and post-operative complication risk abnormal vascular examination neurologic 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 C Preoperative H & P 1 Obtains history and performs basic physical exam evaluate hip range of motion perform neurovascular exam 2 Order basic imaging studies AP and frog lateral pelvis radiographs 3 Perform operative consent describe complications of surgery including redislocation avascular necrosis infection stiffness need for further intervention (including possible pelvic osteotomy now or in the future) Operative Techniques E Preoperative Plan 1 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 2 Identifies potential blocks to reduction F Room Preparation 1 Surgical instrumentation right angle clamp; non absorbable suture (size 0 or 1 Ethibond);spica table and spica casting materials 2 Room setup and equipment setup OR with standard radiolucent operating table c-arm in from contralateral side monitor in surgeon direct line of site on opposite side (or foot) of OR table spica table available for cast placement at end of procedure evaluate femoral anteversion 3 Patient positioning supine small bump under hip (under iliac crest not buttock so gluteal muscles fall away) Prep patient prep medially to umbilicus, superiorly to 12th rib and posteriorly as far as possible G Anterior Approach 1 Mark the incision skin incision 1 cm below iliac crest and inguinal ligament with 2/3 posterior to ASIS, 1/3 anterior to ASIS (approx 6cm posterior and 3cm anterior in toddlers) 2 Make the skin incision perform a sharp dissection through the subcutaneous tissue down to the deep fascia H Deep Dissection 1 Identify the internervous plane identify the interval between the sartorius and the tensor fascia latae (TFL) muscles 2 Identify neurovascular structures identify and protect the lateral femoral cutaneous nerve 3 Develop surgical plane between sartorius and TFL usually done with blunt dissection identify plane (with fat stripe) beginning with hemostat or dissecting scissors continue dissection with army-navy or similar right angle retractors expose bony ridge between ASIS and AIIS I Capsule Exposure 1 Expose the ilium feather external oblique off iliac crest slightly to visualize apophysis incise the iliac apophysis down the middle with a 15 blade "pop" off the lateral half of the apophysis and dissect off the outer table the apophysis on the medial side is left in place unless a pelvic osteotomy is necessary elevate the periosteum on either side and pack 2 Place right angle retractors in TFL-Sartorius interval connect TFL-Sartorius interval to proximal window (exposed ilium) 3 identify rectus femoris tendon and detach as far proximally as possible tag rectus femoris with 2-0 ethibond 4 Place retractors appropriately dissect the TFL origin to the AIIS place a retractor along the medial aspect of the AIIS onto the superior pubic ramus identify the psoas tendon in its groove on the superior pubic ramus place a right angle (e.g. Sofield) retractor medially to retract to overlying psoas muscle belly and expose the underlying tendon the retractor protects the psoas and the neurovascular bundle anteriorly and helps assist in the medial exposure perform an over the brim psoas lengthening to facilitate placement of the right angle retractor in the groove of the superior pubic ramus and expose the anterior hip capsule sufficiently this groove is normally occupied by the iliopsoas 5 Expose the capsule clear hip capsule anteromedially to acetabulum a medium Chandler retractor is placed over the hip capsule superolaterally to allow complete anterior capsular exposure J Capsular Incision 1 Incise the capsule make a T-shaped incision in the anterior hip capsule the first cut is essentially parallel to the acetabulum and runs from superolaterally to inferomedially the second cut is perpendicular to this and runs along the anterior border of the femoral head and neck for more exposure, use Kocher clamps to retract the capsule place tag sutures (size 2-0 Vicryl) in the cut edges of the hip capsule 2 Remove soft tissue attachments identify the femoral head and ligamentum teres detach the ligamentum teres from the femoral head trace the ligamentum teres to the true acetabulum and remove this hypertrophic structure K Acetabular Exposure 1 Expose the entrance to the acetabulum expose the acetabulum laterally, superiorly, medially and inferiorly down to the transverse acetabular ligament the pulvinar must be removed to see the cotyloid fossa and transverse acetabular ligament incise the transverse acetabular ligament to expose and enlarge the most inferior aspect of the acetabulum L Femoral Head Reduction 1 Reduce the femoral head reduce the femoral head into the acetabulum 2 Evaluate the hip reduction move the hip through a complete range of motion identify the safe zone of reduction 3 Perform capsulorrhaphy excise redundant capsule as needed suture the superolateral flap of the T shaped incision as far inferomedially as possible this is done to minimize the amount of redundancy in the false acetabulum place sutures in the tips of the T shaped incision and along the inferior border of the acetabulum and the hip is held in approximately 30 degrees each of hip flexion, abduction and mild internal rotation during capsulorrhaphy 4 Reattach soft tissue suture the rectus femoris to its origin with 2-0 Ethibond close iliac crest with figure 8 sutures of 2-0 Vicryl reapproximating the apophysis a running 2-0 Vicryl is used to approximate the external oblique to its insertion N Wound Closure 1 Irrigation and hemostasis copiously irrigate the wound 2 Fascial closure use 0-vicryl for deep closure, avoid entrapment of LFCN 3 Superficial closure use 2-0 vicryl for the subcutaneous tissue use 3-0 monocryl for skin 4 Dressings and immobilization apply a one and a half leg spica cast with 30 degrees of flexion, 30 degrees of abduction, and mild internal rotation mold posterior to greater trochanter Postoperative Patient Care O Perioperative Inpatient Management 1 Confirm reduction obtain MRI or limited CT scan to confirm reduction 2 Write comprehensive admission orders IV fluids pain control advance diet as tolerated CBC on POD 1 cast care turning every 2 hours while awake and every 4 hours while asleep 3 Discharge patient appropriately pain meds cast care non weightbearing monitor neurologic and vascular status schedule follow up in 1-2 weeks with repeat AP pelvis in cast R Complex Patient Care 1 Develops unique, complex post-operative management plans
A Intermediate Evaluation and Management 1 Recognize vascular, nerve or other associated injuries document neurovascular status 2 Appropriately interprets basic imaging studies and recognizes dislocation or subluxation interpret radiographs of the hip; evaluates acetabulum 3 Makes informed decision to proceed with operative treatment describes indications and contraindications for surgical intervention 4 Provides post-operative management and rehabilitation postop: 1- 2 week postoperative visit check radiographs diagnosis and management of early complications postop: 6 weeks postoperative visit check radiographs remove cast start physical therapy post-op: 3 months postoperative visit check radiographs and range of motion 5 Check radiographs every 1-2 years(until near skeletal maturity) 6 Capable of diagnosis and early management of complications cast problems B Advanced Evaluation and Management 1 Recognizes factors that could predict difficult reduction and post-operative complication risk abnormal vascular examination neurologic 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 C Preoperative H & P 1 Obtains history and performs basic physical exam evaluate hip range of motion perform neurovascular exam 2 Order basic imaging studies AP and frog lateral pelvis radiographs 3 Perform operative consent describe complications of surgery including redislocation avascular necrosis infection stiffness need for further intervention (including possible pelvic osteotomy now or in the future)
E Preoperative Plan 1 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 2 Identifies potential blocks to reduction F Room Preparation 1 Surgical instrumentation right angle clamp; non absorbable suture (size 0 or 1 Ethibond);spica table and spica casting materials 2 Room setup and equipment setup OR with standard radiolucent operating table c-arm in from contralateral side monitor in surgeon direct line of site on opposite side (or foot) of OR table spica table available for cast placement at end of procedure evaluate femoral anteversion 3 Patient positioning supine small bump under hip (under iliac crest not buttock so gluteal muscles fall away) Prep patient prep medially to umbilicus, superiorly to 12th rib and posteriorly as far as possible G Anterior Approach 1 Mark the incision skin incision 1 cm below iliac crest and inguinal ligament with 2/3 posterior to ASIS, 1/3 anterior to ASIS (approx 6cm posterior and 3cm anterior in toddlers) 2 Make the skin incision perform a sharp dissection through the subcutaneous tissue down to the deep fascia H Deep Dissection 1 Identify the internervous plane identify the interval between the sartorius and the tensor fascia latae (TFL) muscles 2 Identify neurovascular structures identify and protect the lateral femoral cutaneous nerve 3 Develop surgical plane between sartorius and TFL usually done with blunt dissection identify plane (with fat stripe) beginning with hemostat or dissecting scissors continue dissection with army-navy or similar right angle retractors expose bony ridge between ASIS and AIIS I Capsule Exposure 1 Expose the ilium feather external oblique off iliac crest slightly to visualize apophysis incise the iliac apophysis down the middle with a 15 blade "pop" off the lateral half of the apophysis and dissect off the outer table the apophysis on the medial side is left in place unless a pelvic osteotomy is necessary elevate the periosteum on either side and pack 2 Place right angle retractors in TFL-Sartorius interval connect TFL-Sartorius interval to proximal window (exposed ilium) 3 identify rectus femoris tendon and detach as far proximally as possible tag rectus femoris with 2-0 ethibond 4 Place retractors appropriately dissect the TFL origin to the AIIS place a retractor along the medial aspect of the AIIS onto the superior pubic ramus identify the psoas tendon in its groove on the superior pubic ramus place a right angle (e.g. Sofield) retractor medially to retract to overlying psoas muscle belly and expose the underlying tendon the retractor protects the psoas and the neurovascular bundle anteriorly and helps assist in the medial exposure perform an over the brim psoas lengthening to facilitate placement of the right angle retractor in the groove of the superior pubic ramus and expose the anterior hip capsule sufficiently this groove is normally occupied by the iliopsoas 5 Expose the capsule clear hip capsule anteromedially to acetabulum a medium Chandler retractor is placed over the hip capsule superolaterally to allow complete anterior capsular exposure J Capsular Incision 1 Incise the capsule make a T-shaped incision in the anterior hip capsule the first cut is essentially parallel to the acetabulum and runs from superolaterally to inferomedially the second cut is perpendicular to this and runs along the anterior border of the femoral head and neck for more exposure, use Kocher clamps to retract the capsule place tag sutures (size 2-0 Vicryl) in the cut edges of the hip capsule 2 Remove soft tissue attachments identify the femoral head and ligamentum teres detach the ligamentum teres from the femoral head trace the ligamentum teres to the true acetabulum and remove this hypertrophic structure K Acetabular Exposure 1 Expose the entrance to the acetabulum expose the acetabulum laterally, superiorly, medially and inferiorly down to the transverse acetabular ligament the pulvinar must be removed to see the cotyloid fossa and transverse acetabular ligament incise the transverse acetabular ligament to expose and enlarge the most inferior aspect of the acetabulum L Femoral Head Reduction 1 Reduce the femoral head reduce the femoral head into the acetabulum 2 Evaluate the hip reduction move the hip through a complete range of motion identify the safe zone of reduction 3 Perform capsulorrhaphy excise redundant capsule as needed suture the superolateral flap of the T shaped incision as far inferomedially as possible this is done to minimize the amount of redundancy in the false acetabulum place sutures in the tips of the T shaped incision and along the inferior border of the acetabulum and the hip is held in approximately 30 degrees each of hip flexion, abduction and mild internal rotation during capsulorrhaphy 4 Reattach soft tissue suture the rectus femoris to its origin with 2-0 Ethibond close iliac crest with figure 8 sutures of 2-0 Vicryl reapproximating the apophysis a running 2-0 Vicryl is used to approximate the external oblique to its insertion N Wound Closure 1 Irrigation and hemostasis copiously irrigate the wound 2 Fascial closure use 0-vicryl for deep closure, avoid entrapment of LFCN 3 Superficial closure use 2-0 vicryl for the subcutaneous tissue use 3-0 monocryl for skin 4 Dressings and immobilization apply a one and a half leg spica cast with 30 degrees of flexion, 30 degrees of abduction, and mild internal rotation mold posterior to greater trochanter
O Perioperative Inpatient Management 1 Confirm reduction obtain MRI or limited CT scan to confirm reduction 2 Write comprehensive admission orders IV fluids pain control advance diet as tolerated CBC on POD 1 cast care turning every 2 hours while awake and every 4 hours while asleep 3 Discharge patient appropriately pain meds cast care non weightbearing monitor neurologic and vascular status schedule follow up in 1-2 weeks with repeat AP pelvis in cast R Complex Patient Care 1 Develops unique, complex post-operative management plans