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Preoperative Patient Care
Operative Techniques
E

Preoperative Plan

1

Radiographic discussion

2

Execute a surgical walkthrough

  • describe steps of the procedure to the attending prior to the start of the case
  • describe potential anatomic dangers of procedure and steps to avoid them.
F

Room Preparation

1

Surgical instrumentation

  • deep right angle retractors and a Cobb elevator
  • drain or penrose catheter

2

Room setup and equipment

  • standard OR table

3

Patient positioning

4

test

  • supine
  • place a bump under the ipsilateral hip to elevate it 25 degrees
G

Anterior Approach

1

Mark the anterior incision

  • flex the hip 90 degrees to develop the crease
  • draw a line that is in line with the skin crease of the anterior hip
  • the incision should be 2cm medial and 2 cm lateral to the ASIS

2

Perform dissection

  • perform sharp dissection through the skin and subcutaneous tissue
  • externally rotate the leg and identify the sartorius
  • identify the interval between the sartorius and tensor fascia lata
  • open the interval using use Metzenbaum scissors, small blunt retractors, or a hemostat
H

Joint Capsule Exposure

1

Identify neurovascular structures

  • identify the lateral femoral cutaneous nerve beneath the fascia on the lateral border of the sartorius
  • retract the nerve medially
  • look for the lateral femoral circumflex vessel branches at the distal portion of the interval.
  • these branches may be coagulated without increasing risk of osteonecrosis to the femoral head
  • identify the direct head of rectus femoris tendon tendon
  • the direct head inserts onto the AIIS
  • identify the indirect head
  • at the proximal extent of the direct head lies the indirect head
  • this will divide and travel out laterally to insert at the junction between the acetabulum and the hip joint capsule

2

Expose the joint capsule

  • use a Cobb elevator for blunt dissection to expose this deeper layer
  • retract the head of the rectus femoris muscle medially
  • this exposes the capsular iliacus and deep capsule of the hip joint
  • use a cobb or peanut retractor and remove any remaining soft tissue from the capsule
I

Arthrotomy

1

Create arthrotomy window

  • use sharp dissection to remove a square window of capsule
  • window can vary in size but typically 1 to 2 cm
J

Cultures

1

Take aerobic and anaerobic cultures

  • include two samples for Gram stain and cell count
K

Irrigation and Stability Assessment

1

Copious irrigate the hip joint

  • irrigate the joint until all purulent material has been removed

2

Check the stability of the joint

  • assess the stability of the joint by placing the hip in extreme positions of abduction and extension
L

Drain Placement and Wound Closure

1

Place penrose drain

2

Close superficial layers with absorbable suture

3

Place soft dressings

Postoperative Patient Care
 

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