Preoperative Patient Care A Intermediate Evaluation and Management 1 Recognize vascular, nerve or other associated injuries document neurovascular status identify if any knee and hip contractures are present 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: 6 week postoperative visit check radiographs diagnose and management of early complications continue non weightbearing change cast postop: 12 week postoperative visit check radiographs start weightbearing once good radiographic healing has been demonstrated check radiographs yearly until skeletal maturity 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 perform neurovascular exam 2 Order basic imaging studies AP and false profile views 3 Perform operative consent describe complications of surgery including stiffness hip subluxation or dislocation nerve palsy closure of triradiate cartilage chondrolysis AVN of the femoral head infection bleeding Operative Techniques E Preoperative Plan 1 Template osteotomy 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 2 Room setup and equipment setup OR with standard operating table c-arm in from contralateral side monitor usually at foot of bed 3 Patient positioning supine slight elevation of involved hemipelvis may be helpful (place "bump" under ipsilateral lumbosacral spine) G Approach 1 Mark the incision (straight "bikini") mark the incision from posterosuperior to anteroinferior to the ASIS the ASIS should be at the midpoint of the incision 2 Determine the internervous plane identify the interval between the sartorius and the tensor fascia latae muscles 3 Identify neurovascular structures identify and protect the lateral femoral cutaneous nerve identify and coagulate the lateral femoral circumflex vessels in the distal portion of the tensor-sartorius interval H Deep Dissection 1 Expose the ilium split the iliac apophysis start at the ASIS and extend as far along as possible subperiosteally dissect the TFL laterally to expose the ilium and the full extent of the anterolateral capsule 2 Expose the outer (and usually the inner) tables of the ilium perform subperiosteal dissection to the sciatic notch bleeding from bony nutrient foramen should be controlled place a retractor (like a Chandler) in the sciatic notch from the lateral (and medial) sides to protect the neurovascular structures release the reflected head of the rectus and follow posteriorly I Osteotomy 1 Map out the osteotomy insert guidewire starting just cephalad to the AIIS and directed towards the inner wall just above the triradiate cartilage advance the guidewire under fluoroscopy using AP and obturator oblique views the wire will serve as a guide for the level and orientation of the osteotomy 2 Perform the osteotomy starting point will be just above the AIIS plan to leave at least 1-1.5 cm intact bone above the acetabulum starting laterally, use an osteotome to cut the ililum in a medial and inferior direction in line with the guidewire towards the medial end of the triradiate cartilage the posterior third of the ilium should be left intact because it will act as a fulcrum for rotation the less the inner wall is cut, the more the lateral coverage will be with rotation the thinner the roof fragment is the deeper the coverage J Mobilization and correction 1 Mobilization Lever the cortex down with a wide osteotome to achieve the desired correction/coverage evaluate correction under fluoroscopy 2 Choose type of graft allograft wedges and autograft wedges from the iliac crest or from a concurrent femoral shortening osteotomy 3 Hold the osteotomy open and stabilize acetabular correction bone graft is usually triangular-shaped size of bone graft is estimated when the osteotomy site is being levered down to achieve desired correction/coverage insert the wedges from a lateral to medial direction it is important to place the largest piece of graft where the most coverage is needed bone graft should be stable when wedged into ilium 4 Evaluate correction with fluoroscopy 5 Assess range of motion K Soft Tissue Reattachment 1 Reattach the apophysis 2 Reattach musculature L Wound Closure 1 Irrigation and hemostasis copiously irrigate the wound 2 Deep closure use 0-vicryl for deep closure 3 Superficial closure use 2-0 or 3-0 vicryl for the subcutaneous tissue use 3-0 monocryl (or comparable suture) for skin 4 Dressings and immobilization apply soft dressing to incision site apply spica cast Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids pain control advance diet as tolerated check appropriate labs wound care 2 Discharge patient appropriately pain meds non weightbearing monitor neurological and vascular status schedule follow up in 6 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans
A Intermediate Evaluation and Management 1 Recognize vascular, nerve or other associated injuries document neurovascular status identify if any knee and hip contractures are present 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: 6 week postoperative visit check radiographs diagnose and management of early complications continue non weightbearing change cast postop: 12 week postoperative visit check radiographs start weightbearing once good radiographic healing has been demonstrated check radiographs yearly until skeletal maturity 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 perform neurovascular exam 2 Order basic imaging studies AP and false profile views 3 Perform operative consent describe complications of surgery including stiffness hip subluxation or dislocation nerve palsy closure of triradiate cartilage chondrolysis AVN of the femoral head infection bleeding
E Preoperative Plan 1 Template osteotomy 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 2 Room setup and equipment setup OR with standard operating table c-arm in from contralateral side monitor usually at foot of bed 3 Patient positioning supine slight elevation of involved hemipelvis may be helpful (place "bump" under ipsilateral lumbosacral spine) G Approach 1 Mark the incision (straight "bikini") mark the incision from posterosuperior to anteroinferior to the ASIS the ASIS should be at the midpoint of the incision 2 Determine the internervous plane identify the interval between the sartorius and the tensor fascia latae muscles 3 Identify neurovascular structures identify and protect the lateral femoral cutaneous nerve identify and coagulate the lateral femoral circumflex vessels in the distal portion of the tensor-sartorius interval H Deep Dissection 1 Expose the ilium split the iliac apophysis start at the ASIS and extend as far along as possible subperiosteally dissect the TFL laterally to expose the ilium and the full extent of the anterolateral capsule 2 Expose the outer (and usually the inner) tables of the ilium perform subperiosteal dissection to the sciatic notch bleeding from bony nutrient foramen should be controlled place a retractor (like a Chandler) in the sciatic notch from the lateral (and medial) sides to protect the neurovascular structures release the reflected head of the rectus and follow posteriorly I Osteotomy 1 Map out the osteotomy insert guidewire starting just cephalad to the AIIS and directed towards the inner wall just above the triradiate cartilage advance the guidewire under fluoroscopy using AP and obturator oblique views the wire will serve as a guide for the level and orientation of the osteotomy 2 Perform the osteotomy starting point will be just above the AIIS plan to leave at least 1-1.5 cm intact bone above the acetabulum starting laterally, use an osteotome to cut the ililum in a medial and inferior direction in line with the guidewire towards the medial end of the triradiate cartilage the posterior third of the ilium should be left intact because it will act as a fulcrum for rotation the less the inner wall is cut, the more the lateral coverage will be with rotation the thinner the roof fragment is the deeper the coverage J Mobilization and correction 1 Mobilization Lever the cortex down with a wide osteotome to achieve the desired correction/coverage evaluate correction under fluoroscopy 2 Choose type of graft allograft wedges and autograft wedges from the iliac crest or from a concurrent femoral shortening osteotomy 3 Hold the osteotomy open and stabilize acetabular correction bone graft is usually triangular-shaped size of bone graft is estimated when the osteotomy site is being levered down to achieve desired correction/coverage insert the wedges from a lateral to medial direction it is important to place the largest piece of graft where the most coverage is needed bone graft should be stable when wedged into ilium 4 Evaluate correction with fluoroscopy 5 Assess range of motion K Soft Tissue Reattachment 1 Reattach the apophysis 2 Reattach musculature L Wound Closure 1 Irrigation and hemostasis copiously irrigate the wound 2 Deep closure use 0-vicryl for deep closure 3 Superficial closure use 2-0 or 3-0 vicryl for the subcutaneous tissue use 3-0 monocryl (or comparable suture) for skin 4 Dressings and immobilization apply soft dressing to incision site apply spica cast
O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids pain control advance diet as tolerated check appropriate labs wound care 2 Discharge patient appropriately pain meds non weightbearing monitor neurological and vascular status schedule follow up in 6 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans