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Open Reduction of Congenital Hip Dislocation

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

 

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