0%
TECHNIQUE VIDEO
0%
TECHNIQUE STEPS
 
0
0
0%
Evidence
4 4
0
0
TECHNIQUE STEPS
Preoperative Patient Care
Operative Techniques
E

Preoperative Plan

1

Template reduction

  • determine the slip angle and percent displacement

2

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
F

Room Preparation

1

Surgical instrumentation

  • 6.5 or 7.3 mm cannulated screws

2

Room setup and equipment

  • setup OR with standard radiolucent operating table
  • fracture table is an option
  • C-arm in from contralateral side of bed
  • monitor in surgeon direct line of site at foot of bed
  • flex the hip 90 degrees and abduct 45 degrees to obtain lateral views

3

Patient positioning

  • supine
  • pad the ipsilateral arm and position across the chest
G

Guidewire Placement

1

Identify the course of the guidewire

  • use imaging to identify the femoral neck at its longest
  • internally and externally rotate the hip until the femoral neck appears to be at its longest
  • the femoral neck should be should be horizontal to the operating table and perpendicular to the image beam

2

Align the guidewire

  • place a guidewire on the anterior hip and align the point of the guidewire over the center of the femoral head
  • align the guidewire along the neck
  • mark the skin along the guidewire to identify the planned trajectory of the wire
  • this will represent the trajectory the guide pin should follow on the AP images
H

Determination of the Femoral Neck Entry Point

1

With unstable SCFEs, before manipulation of the leg for lateral views, consider initial temporary fixation of the epiphysis (usually with a guidewire).

2

Determine the path of the bone screw in the sagittal plane

  • flex hip 90 degrees and abduct the hip 45 degrees
  • align the guide wire along the neck over the center of the femoral head
  • this represents the desired path of the screw in the sagittal plane
  • the point that this line crosses the femoral neck is the entry point for the guidewire
I

Skin Entry Site Determination

1

Mark the skin incision

  • example
  • if the slip angle measured is 30 degrees, the entry point on the skin should be 30 degrees from the lateral palpable femoral shaft towards the femoral head

2

Make a skin incision

  • make a 1 cm incision through the skin and spread with the hemostat down to the bone along the line that was previously drawn
  • the point of the guidepin should be positioned on the anterolateral femoral neck where the entry was estimated
  • entry point should be lateral to the intertrochanteric line (on AP view) to avoid screw head impingement
J

Guide Pin Insertion

1

Drill and advance the guidepin

  • drill the guidepin into the midpoint of the femoral neck

2

Check pin placement

  • confirm the position with imaging
  • once the position of the guidepin is confirmed advance the guidepin to within 3 mm of the articular surface and the length is measured
  • should be center center in the EPIPHYSIS

3

Confirm guide pin position

  • confirm the final position of the guidepin with multiple radiographic images
  • must be out of the joint on all images
K

Drilling and Cannulated Screw Placement

1

Measure the length of the cannulated screw

  • measure the guidewire with the cannulated screw depth gauge to determine the desired screw length

2

Place cannulated screw

  • use the cannulated drill over the guidewire
  • stop the drill 1 or 2 mm before the tip of the guidewire
  • drill must cross the physis
  • place a 6.5 mm to a 7.3 mm cannulated screw over the guidewire
  • remove the guidewire
  • single screw fixation is usually favorable
  • compared to multiple screws, lower risk of osteonecrosis and intraarticular penetration
L

Radiographic Evaluation

1

Ensure placement of the cannulated screw

  • use spot AP and frog leg lateral fluoroscopy to ensure placement
  • attempt if possible to have five threads of the screw within the epiphysis to decrease the risk of slip progression

2

Test for penetration into the joint

  • use the "approach and withdraw" method to ensure that the screw tip remains in the femoral head
  • under fluoroscopy range the hip from internal to external rotation at varying degrees of flexion
  • watch to see if the screw tip approaches and withdraws from the subchondral bone
N

Wound Closure

1

Irrigation and hemostasis

  • copiously irrigate the wound

2

Deep closure

  • use 0-vicryl for deep closure

3

Superficial closure

  • use 2-0 vicryl for the subcutaneous tissue
  • use 3-0 monocryl for skin

4

Dressings and immobilization

  • place a soft dressing on the incision
Postoperative Patient Care
 

Please rate topic.

Average 4.3 of 3 Ratings

Evidences (4)
Topic COMMENTS (1)
Private Note