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Psoas Lengthening

Preoperative Patient Care

A

Intermediate Evaluation and Management

1

Obtains focused history and physical

  • history
  • difficulty with gait, fatiguing readily secondary to a crouch gait
  • gait plateauing or deteriorating in a child over the age of 6
  • symptoms
  • Gait deteriorating
  • crouch gait
  • fatiguing with walking short distances
  • physical exam
  • positive Thomas test with hip contracture greater than 10 degrees
  • evaluates ROM of knees and ankles as well
  • evaluates and documents gait
  • recognizes factors that could predict complications or poor outcome
  • weakness of hip flexor less than 3/5
  • child who is making great functional gains in walking is not a good candidate for surgery, it should be held until they plateau or regress
  • dystonia is a contraindication for tendon lengthening

2

Orders and interprets required diagnostic studies

  • AP and Frog Pelvis Xray
  • Spine Xrays if concerned for lumbar lordosis
  • Computerized gait analysis, when available

3

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • physical therapy
  • prone positioning
  • describes accepted indications and contraindications for surgical intervention
  • Indications
  • hip flexion in terminal stance with a static hip contracture of at least 10 degrees
  • contraindications
  • excessive weakness of psoas muscle
  • child who is making rapid functional progress, surgery can interfere with functional progress and should be held until the child plateaus or regresses
  • dystonia

4

Postop: 3-4 Week Postoperative Visit

  • wound check
  • Thomas test
  • start active hip flexor strengthening exercises at 3 weeks
  • diagnose and management of early complications
  • evaluate for signs/symptoms of infection
  • evaluate for signs/symptoms of neurovascular injury
B

Advanced Evaluation and Management

1

Modifies post-operative plan based on response to treatment

  • patient fails to improve post-operatively
  • asses compliance and reinforce compliance with prone program at home
  • check hip xrays
  • physical therapy to focus on range of motion and strengthening
  • obtain postoperative gait analysis to asses multilevel issues
C

Preoperative H & P

1

Obtains history and performs basic physical exam

  • check range of motion, Thomas test to evaluate for static hip flexion contracture
  • asses hip abduction and extension. Galeazzi test and Allis test for leg lengths
  • check range of motion at knee and ankle, evaluate for increased muscle tone
  • evaluate spine for increased lumbar lordosis
  • thorough neurovascular examination of lower extremities
  • evaluate child's gait for precence of a crouch gait
  • identify medical co-morbidities that might impact surgical treatment

2

Screen medical studies to identify and contraindications for surgery

3

Orders appropriate initial imaging and laboratory studies

  • ap/frog pelvis xray to assess for hip subluxation
  • gait analysis when available should be ordered. A gait analysis evaluates multilevel pathology that should be addressed at one surgical procedure when present.

4

Perform operative consent

  • describe complications of surgery including
  • excessive hip flexor weakness with tendon release at the lesser trochanter
  • femoral neurovascular injury
  • recurrence
  • instability
  • worsened anterior pelvic tilt

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
  • Sofield or other right angle retractors

2

Room setup and equipment

  • standard OR table, but may use radiolucent table if this is being done as part of a SEMLS procedure (single event multilevel surgery)
  • headlight may be used for large patients

3

Patient positioning

  • supine
  • place a bump under the ipsilateral hip to elevate it in unilateral cases
G

Skin Incision

1

Make the oblique incision

  • localize and mark out artery on skin prior to incision
  • make and oblique 5 cm anterior bikini incision just distal to the ASIS
  • start the incision just distal to the the ASIS and extend the incision distally and medially
H

Deep Dissection

1

Identify the tensor fascia lata/ sartorius interval

2

Open the Tensor fascia lata/sartorius interval

  • place a hemostat or tenotomy scissors into soft spot below the ASIS and open the fascia
  • open and identify fat stripe that is associated with the lateral femoral cutaneous nerve
  • isolate and protect the nerve.
  • deep to the interval is the rectus femoris tendon.
  • dissection is carried out medial to this and the pelvic brim is palpated
  • flex the hip and the psoas tendon and muscle can be identified
I

Psoas Identification

1

Expose the psoas tendon

  • flex the hip
  • place a sofield retractor under the psoas muscle to elevate it
  • slide the sofield retractor along the undersurfrace of the psoas muscle and the psoas tendon will roll into view
  • use a tenotomy to open the fascia over the psoas tendon
  • place a right angle retractor around psoas tendon islolating it from the muscle

2

Identify the psoas tendon with 3 essential tests prior to cutting

  • #1 identify the muscle fibers entering the psoas tendon
  • #2 confirm it is the psoas tendon by noting the musculotendinous junction tightens with internal rotation of the hip
  • #3 make sure the leg does not "jump" with brief stimulation of the tendon with electrocautery
J

Psoas Lengthening

1

Perform lengthening

  • retract the muscle fibers
  • divide the tendon with electrocautery
  • be sure to leave the muscle intact
  • identify any inflexible tissue and divide it
K

Wound Closure

1

Wound closure

  • close the subcutaneous tissue with interrupted 2.0 absorbable suture
  • close the skin with a running absorbable 3.0 monofilament suture

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • advance diet as tolerated
  • IV fluids
  • pain control
  • physical therapy
  • avoid hip flexion
  • place in the prone position 3 times per day for at least 2 hours for a total of 6 hours a day
  • wound management
  • remove dressings POD2

2

Discharges patient appropriately

  • pain control
  • provides patient with oral narcotic medication to be taken as needed for two weeks
  • provides patient with oral diazepam two week supply to be taken as needed for spasticity
  • schedule follow up in 2 weeks
  • wound care
  • dressing can be removed on postoperative day 2 and can be left uncovered
  • unless there is concern for soiling of wound then keeping it covered with an impervious dressing until the postoperative visit is recommended
R

Complex Patient Care

1

Develop a comprehensive preoperative plan that includes options based on intraoperative findings

  • perform observational gait analysis and when possible interpret motion lab gait analysis to incorporate these findings in a preoperative plan
  • demonstrates understanding of other factors that contribute to crouch gait, hamstring tightness, excessiv ankle dorsiflexiion
  • able to problem solve these issues with bracing and surgical intervention planning preoperatively so the child undergoes a Single Event Multilevel Surgery when necessary
 

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