Preoperative Patient Care A Intermediate Evaluation and Management 1 Postop: 3-4 Week Postoperative Visit wound check remove cast hip abduction orthosis is used at night for 6 to 12 months postoperatively. begin physical therapy, focusing on range of motion, gait, and strengthening, after cast removal. B Advanced Evaluation and Management 1 Modifies post-operative plan based on response to treatment patient fails to improve post-operatively C Preoperative H & P 1 Obtains history and performs basic physical exam check hip range of motion visual gait assessment (observe the child walking) identify medical co-morbidities that might impact surgical treatment 2 Orders appropriate imaging AP and frog lateral pelvis to evaluate hip joint 3 Performs operative consent describe complications of surgery including abduction contractures if obturator nerve is injured recurrent deformity bleeding infection Operative Techniques E Preoperative Plan 1 Execute a surgical walkthrough describe steps of the procedure to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation right angle clamp right angle retractors 2 Room setup and equipment standard OR table (radiolucent if bone procedures being performed also) 3 Patient positioning supine G Skin Incision 1 Make a transverse incision make a 3-4 cm transverse incision in the proximal groin crease. 2 Perform dissection use bovie electrocautery through the subcutaneous tissue incise the fascia in line with the skin incision. H Adductor Longus Tenotomy 1 Identify the adductor longus palpate adductor longus anteriorly. adductor longus is usually the tightest tendon 2 Isolate adductor longus isolate tendon from surrounding tissue with a clamp and/or finger. place right-angle clamp around the adductor longus slide the clamp as proximally as possible 3 Perform tenotomy use electrocautery to transect the musculotendinous unit do NOT perform an obturator neurectomy because of the frequent occurrence of overcorrection and fixed abduction following such surgery. I Gracilis Tenotomy 1 Identify and isolate the gracilis tendon the gracilis can be identified and isolated by abducting the hip and extending the knee this places the gracilis on tension 2 Perform tenotomy use electrocautery to transect the muscle as proximal as possible J Wound Closure 1 Deep closure close the fascia (if possible) to prevent drainage 2 Superficial closure close the subcutaneous layer. subcuticular closure - consider using surgical glue on skin 3 Immobilization place the child in an A-frame cast with legs abducted at least 25 to 30° for 3 to 4 weeks use hip abduction pillow or orthosis as an alternative Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive admission orders advance diet as tolerated IV fluids pain control wound management many surgeons leave these in place unless soiled, but some prefer to remove dressings on POD2 2 Discharges patient appropriately pain control schedule follow up in 2 weeks R Complex Patient Care 1 Able to develop a comprehensive preoperative plan that includes options based on intraoperative findings managing dislocated hip
A Intermediate Evaluation and Management 1 Postop: 3-4 Week Postoperative Visit wound check remove cast hip abduction orthosis is used at night for 6 to 12 months postoperatively. begin physical therapy, focusing on range of motion, gait, and strengthening, after cast removal. B Advanced Evaluation and Management 1 Modifies post-operative plan based on response to treatment patient fails to improve post-operatively C Preoperative H & P 1 Obtains history and performs basic physical exam check hip range of motion visual gait assessment (observe the child walking) identify medical co-morbidities that might impact surgical treatment 2 Orders appropriate imaging AP and frog lateral pelvis to evaluate hip joint 3 Performs operative consent describe complications of surgery including abduction contractures if obturator nerve is injured recurrent deformity bleeding infection
E Preoperative Plan 1 Execute a surgical walkthrough describe steps of the procedure to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation right angle clamp right angle retractors 2 Room setup and equipment standard OR table (radiolucent if bone procedures being performed also) 3 Patient positioning supine G Skin Incision 1 Make a transverse incision make a 3-4 cm transverse incision in the proximal groin crease. 2 Perform dissection use bovie electrocautery through the subcutaneous tissue incise the fascia in line with the skin incision. H Adductor Longus Tenotomy 1 Identify the adductor longus palpate adductor longus anteriorly. adductor longus is usually the tightest tendon 2 Isolate adductor longus isolate tendon from surrounding tissue with a clamp and/or finger. place right-angle clamp around the adductor longus slide the clamp as proximally as possible 3 Perform tenotomy use electrocautery to transect the musculotendinous unit do NOT perform an obturator neurectomy because of the frequent occurrence of overcorrection and fixed abduction following such surgery. I Gracilis Tenotomy 1 Identify and isolate the gracilis tendon the gracilis can be identified and isolated by abducting the hip and extending the knee this places the gracilis on tension 2 Perform tenotomy use electrocautery to transect the muscle as proximal as possible J Wound Closure 1 Deep closure close the fascia (if possible) to prevent drainage 2 Superficial closure close the subcutaneous layer. subcuticular closure - consider using surgical glue on skin 3 Immobilization place the child in an A-frame cast with legs abducted at least 25 to 30° for 3 to 4 weeks use hip abduction pillow or orthosis as an alternative
O Perioperative Inpatient Management 1 Write comprehensive admission orders advance diet as tolerated IV fluids pain control wound management many surgeons leave these in place unless soiled, but some prefer to remove dressings on POD2 2 Discharges patient appropriately pain control schedule follow up in 2 weeks R Complex Patient Care 1 Able to develop a comprehensive preoperative plan that includes options based on intraoperative findings managing dislocated hip