Updated: 10/4/2016

Surgical Dislocation of the Hip

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

 

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