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 fracture patterns interpret radiographs of the hip 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 4 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit check radiographs diagnose and management of early complications continue one sixth body weight partial weightbearing check incision postop: 6 week postoperative visit check radiographs start weightbearing start hip strengthening exercises identify delayed unions 5 Capable of diagnosis and early management of complications B Advanced Evaluation and Management 1 Recognizes factors that could predict difficult reduction and post-operative complication risk abnormal vascular examination neurological 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 2 Check range of motion of the hip document flexion, extension, rotation in both flexion and extension, abduction, and adduction while feeling for SOFT end points 3 Perform neurovascular exam 4 Order basic imaging studies AP and true lateral radiographs of the hip held in 15 to 20 degrees of internal rotation Modified Dunn to show asphericity of the femoral head 5 Perform operative consent describe complications of surgery including femoral neck fracture avascular necrosis of the femoral head greater trochanter nonunion heterotopic ossification repeat labral tear continued arthrosis of the joint sciatic or femoral nerve neurapraxia Operative Techniques E Preoperative Plan 1 Template dislocation 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 3.5 or 4.5 cannulated or non-cannulated screws osteotomy templates osteotomes burr with round tip 2 Room setup and equipment setup OR with standard operating table peg board or lateral hip positioner C-arm in from contralateral side monitor in surgeon direct line of site at foot of bed flex the hip 90 degrees and abduct 45 degrees to obtain lateral views check patient range of motion BEFORE turning lateral 3 Patient positioning full lateral with a peg board or hip positioner G Approach to the Hip Capsule 1 Mark and make the incision center the incision over the junction between the anterior and middle thirds of the greater trochanter make straight, longitudinal skin incision in line with femur split the fascia lata distally in line with the incision continue the proximal dissection through the interval between the anterior edge of the of the gluteus maximus and the tensor OR split gluteus maximus incise the most proximal 4 to 5 cm of the vastus lateralis just anterior to gluetus maximus tendon elevate the vastus muscle anteriorly, staying extra-periosteal 2 Find and develop interval between piriformis and gluteus medius identify capsule deep to gluteus medius leave the gluteus minimus connected to the gluteus maximus 3 Perform trochanteric osteotomy extends from superoposterior corner of trochanter to vastus ridge should be approximately 15mm thick leave the piriformis tendon and the short external rotators intact on the remaining base of the greater trochanter reflect the trochanteric flip piece anteriorly along with its muscle attachments 4 Expose the hip capsule elevate the capsular minimus anteriorly dissect the interval between posterior edge of the capsular minimus and the piriformis tendon expose the capsule up to the rim of the acetabulum both superiorly and anteriorly H Hip Arthrotomy 1 Perform capsulotomy make a Z shaped capsulotomy with the longitudinal arm of the Z in line with the anterior neck of the femur first cut in line with the inferior femoral neck extending proximally to labrum extend the distal arm of the capsulotomy anteriorly and remain proximal to the lesser trochanter extend the proximal arm posteriorly along the acetabular rim just distal to the labrum and proximal to the retinacular branches of the medial femoral circumflex artery I Dislocation 1 Test for areas of impingement bring the hip through a full range of motion to test for areas of impingement 2 Dislocate the hip place the leg in the sterile side bag flex, externally rotate and adduct the hip while the hip is subluxated anteriorly through the arthrotomy place a bone hook anteriorly on the femoral neck to assist in subluxation of the hip divide the ligamentum teres using curved meniscus scissors to allow full dislocation of the hip J Dynamic Assessment 1 dynamic assessment check the entire femoral head and acetabulum for chondral flaps/tears or labral tears K Osteoplasty 1 Resect aspherical segment of the femoral head while respecting blood supply to femoral head use a quarter inch osteotome and rongeur to resect aspherical segments at the head-neck junction use burr to smooth head-neck junction 2 Reassess the hip reduce the hip and assess the results of the osteoplasty by taking the hip through a full range of motion look for impingement and/or instability 3 Confirm re-establishment of the femoral head-neck offset radiographically take AP and lateral of the hip with the hip in 90 degrees of flexion L Osteotomy Fixation 1 Reduce the trochanteric flip piece use towel clamp to control the fragment and a ball-spike to maintain reduction 2 Secure the trochanteric wafer use two-three 3.5 mm or 4.5 mm screws to secure the trochanteric flip piece 3 Confirm the reduction with fluoroscopy N Wound Closure 1 Irrigation and hemostasis copiously irrigate the wound 2 Close the capsulotomy perform repair of the capsulotomy 3 Repair soft tissues close the fascia of the vastus lateralis with absorbable running suture 4 Deep closure close tensor fascia and gluteal fascia 5 Superficial closure use 2-0 vicryl for the subcutaneous tissue use 3-0 monocryl for skin 6 Dressings and immobilization place a soft dressing on the incision Postoperative Patient Care 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 when to remove dressings 2 Discharge patient appropriately pain meds touch down weight bearing monitor neurological and vascular status schedule follow up in 2 weeks 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 fracture patterns interpret radiographs of the hip 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 4 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit check radiographs diagnose and management of early complications continue one sixth body weight partial weightbearing check incision postop: 6 week postoperative visit check radiographs start weightbearing start hip strengthening exercises identify delayed unions 5 Capable of diagnosis and early management of complications B Advanced Evaluation and Management 1 Recognizes factors that could predict difficult reduction and post-operative complication risk abnormal vascular examination neurological 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 2 Check range of motion of the hip document flexion, extension, rotation in both flexion and extension, abduction, and adduction while feeling for SOFT end points 3 Perform neurovascular exam 4 Order basic imaging studies AP and true lateral radiographs of the hip held in 15 to 20 degrees of internal rotation Modified Dunn to show asphericity of the femoral head 5 Perform operative consent describe complications of surgery including femoral neck fracture avascular necrosis of the femoral head greater trochanter nonunion heterotopic ossification repeat labral tear continued arthrosis of the joint sciatic or femoral nerve neurapraxia
E Preoperative Plan 1 Template dislocation 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 3.5 or 4.5 cannulated or non-cannulated screws osteotomy templates osteotomes burr with round tip 2 Room setup and equipment setup OR with standard operating table peg board or lateral hip positioner C-arm in from contralateral side monitor in surgeon direct line of site at foot of bed flex the hip 90 degrees and abduct 45 degrees to obtain lateral views check patient range of motion BEFORE turning lateral 3 Patient positioning full lateral with a peg board or hip positioner G Approach to the Hip Capsule 1 Mark and make the incision center the incision over the junction between the anterior and middle thirds of the greater trochanter make straight, longitudinal skin incision in line with femur split the fascia lata distally in line with the incision continue the proximal dissection through the interval between the anterior edge of the of the gluteus maximus and the tensor OR split gluteus maximus incise the most proximal 4 to 5 cm of the vastus lateralis just anterior to gluetus maximus tendon elevate the vastus muscle anteriorly, staying extra-periosteal 2 Find and develop interval between piriformis and gluteus medius identify capsule deep to gluteus medius leave the gluteus minimus connected to the gluteus maximus 3 Perform trochanteric osteotomy extends from superoposterior corner of trochanter to vastus ridge should be approximately 15mm thick leave the piriformis tendon and the short external rotators intact on the remaining base of the greater trochanter reflect the trochanteric flip piece anteriorly along with its muscle attachments 4 Expose the hip capsule elevate the capsular minimus anteriorly dissect the interval between posterior edge of the capsular minimus and the piriformis tendon expose the capsule up to the rim of the acetabulum both superiorly and anteriorly H Hip Arthrotomy 1 Perform capsulotomy make a Z shaped capsulotomy with the longitudinal arm of the Z in line with the anterior neck of the femur first cut in line with the inferior femoral neck extending proximally to labrum extend the distal arm of the capsulotomy anteriorly and remain proximal to the lesser trochanter extend the proximal arm posteriorly along the acetabular rim just distal to the labrum and proximal to the retinacular branches of the medial femoral circumflex artery I Dislocation 1 Test for areas of impingement bring the hip through a full range of motion to test for areas of impingement 2 Dislocate the hip place the leg in the sterile side bag flex, externally rotate and adduct the hip while the hip is subluxated anteriorly through the arthrotomy place a bone hook anteriorly on the femoral neck to assist in subluxation of the hip divide the ligamentum teres using curved meniscus scissors to allow full dislocation of the hip J Dynamic Assessment 1 dynamic assessment check the entire femoral head and acetabulum for chondral flaps/tears or labral tears K Osteoplasty 1 Resect aspherical segment of the femoral head while respecting blood supply to femoral head use a quarter inch osteotome and rongeur to resect aspherical segments at the head-neck junction use burr to smooth head-neck junction 2 Reassess the hip reduce the hip and assess the results of the osteoplasty by taking the hip through a full range of motion look for impingement and/or instability 3 Confirm re-establishment of the femoral head-neck offset radiographically take AP and lateral of the hip with the hip in 90 degrees of flexion L Osteotomy Fixation 1 Reduce the trochanteric flip piece use towel clamp to control the fragment and a ball-spike to maintain reduction 2 Secure the trochanteric wafer use two-three 3.5 mm or 4.5 mm screws to secure the trochanteric flip piece 3 Confirm the reduction with fluoroscopy N Wound Closure 1 Irrigation and hemostasis copiously irrigate the wound 2 Close the capsulotomy perform repair of the capsulotomy 3 Repair soft tissues close the fascia of the vastus lateralis with absorbable running suture 4 Deep closure close tensor fascia and gluteal fascia 5 Superficial closure use 2-0 vicryl for the subcutaneous tissue use 3-0 monocryl for skin 6 Dressings and immobilization place a soft dressing on the incision
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 when to remove dressings 2 Discharge patient appropriately pain meds touch down weight bearing monitor neurological and vascular status schedule follow up in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans