Updated: 10/4/2016

Adductor Lengthening

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
 

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