Preoperative Patient Care A Outpatient Evaluation and Management 1 Obtains focused history and performs focused exam check neurovascular status compare extremity to contralateral limb concomitant and associated orthopaedic injuries 2 Appropriately interprets basic imaging studies interpret AP pelvis and lateral radiographs of the affected hip 3 Recognition / evaluation of fragility fractures order appropriate workup and/or consult 4 Interacts with consultants regarding optimal patient management timing of surgery medical management assess risk for thromboembolic disease 5 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 6 Provides post-operative management and rehabilitation; WB status postop: 2-3 Week postoperative visit wound check diagnose and management of early complications staples/sutures removed continue physical therapy and range of motion exercises repeat xrays of femur postop: ~ 3 month postoperative visit diagnosis and management of late complications repeat xrays of femur postop: 1 year postoperative visit B Advanced Evaluation and Management 1 Comprehensive assessment of fracture patterns on imaging studies 2 Interpretation of diagnostic studies for fragility fractures with appropriate management and/or referral 3 Arranges for long term management of geriatric patients management of bone health discharge planning to long term care 4 Modifies and adjusts post-operative treatment plan as needed 5 Provides prohylaxis and manages thromboemblotic disease C Preoperative H & P 1 Perform focus orthopaedic history and physical perform careful extremity exam document distal neurovascular status identify associated injuries and comorbidities identify patient comorbidities and ASA status (predictor of mortality) screen medical studies to identify and contraindications for surgery 2 Order basic imaging studies order AP pelvis, ap and lateral of affected hip 3 Perform operative consent including lists potential complications describe complications of surgery including medical complications including death definitive stabilization within 48-72h associated with decreased pulmonary complications, thromboembolic events, length of hospital stay, and morbidity/mortality varus collapse with screw cut out AVN of the femoral head Operative Techniques E Preoperative Plan 1 Template intramedullary nail and cephalomedullary screws measure the size of the hip screw 2 Surgical walkthrough resident can describe key steps of the operation verbally to attending prior to beginning of case. list potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation DHS system 2 Room setup and equipment radiolucent fracture table (Jackson fracture) c-arm fluoroscopy 3 Patient positioning make sure patient has Foley urinary catheter in place patient supine with feet padded with webril and placed firmly in fracture table boots if contralateral leg dropped down, if raising contralateral leg up 90° use thigh holder padded post deep into groin, move genitals and Foley catheter out of the way ipsilateral arm on stack of blankets over chest and taped down, contralateral arm on arm board prep and drape entire leg up to iliac crest to make sure adequate working area c-arm from contralateral side at 45° towards hip take initial fluoro AP/Lat of hip to examine femoral neck mark position of C-arm to ensure proper positioning during remainder of case (~15° tilt for correct AP xray of hip) G Lateral Approach to the Hip 1 Mark and make the incision make straight lateral incision two finger breadths below the vastus ridge to a point 5-7 cm distally 2 Dissect down to the IT band perform subperiosteal dissection to sweep the subcutaneous tissue from either side of the IT band 3 Incise the fascia lata make an incision in line with the fascia lata 4 Place retractors place Charnley retractor deep to the IT band use blunt dissection between the vastus lateralis and the IT band to remove the adhesions 5 Retract the vastus lateralis anteriorly 6 Expose the bone elevate the posterior portion of the vastus lateralis off to expose bone use a periosteal elevator too bluntly split the posterior 20% of the vastus directly down to bone, and then elevate it off the bone 7 Place Benet retractors insert 2 large Bennet retractors over the anterior edge of the femur, and rest the retractor handles underneath the previously applied Charnely retractor use a periosteal elevator to strip the remaining tissue from the lateral aspect of the femur H Fracture Reduction and Guidepin Placement 1 Reduce the fracture 2 Determine the degree of anteversion determine the amount of anteversion by placing the DHS/DCS guide pin anteriorly along the femoral neck with the use of the appropriate DHS angle guide 3 Place the pin gently hammer the pin into the femoral head this anteversion pin will later allow the correct placement of the central guide pin in the center of the femoral head 4 Align the DHS angle guide align the appropriate DHS angle guide along the axis of the femoral shaft 5 Place the DHS angle guide on the femur point the guide tube toward the center of the femoral head 6 Place the guidepin it is recommended to predrill the lateral cortex with a 2.0 mm drill bit due to the density of the bone insert a DHS/DCS guide pin through the appropriate DHS angle guide this should be parallel to the anteversion pin and directed toward the center of the femoral head this point of introduction will vary with the barrel angle when the 135 degree barrel angle is used, enter the guide pin through the proximal femur approximately 2.5 cm distal to the vastus ridge I Confirm Placement of the Guidepin and Insertion of Depth Measurement 1 Confirm the placement of the guidepin use image intensification to confirm the placement of the DHS/DCS guide pin under image intensification the pin must lie along the axis of the femoral neck in both the AP and lateral views and parallel to the anteversion pin 2 Remove the anteversion pin 3 Check guidepin insertion depth slide the direct measuring device over the guide pin to determine guide pin insertion depth the calibration on the device provides a direct reading calculate the reaming depth, tapping depth and lag screw length subtract 10 mm from the reading 4 Assemble the appropriate DHS triple reamer J Reaming 1 Set and place the reamer set the reamer to the correct depth insert the DHS triple reamer into the power drive using the large quick coupling attachment slide the reamer over the guide pin to simultaneously drill for the plate/barrel junction to the preset depth when reaming into the dense bone, continuously irrigate the DHS triple reamer to prevent thermal necrosis if needed tap to the predetermined depth using the Tap Assembly tapping depth can be seen through the window in the short centering sleeve K Lag Screw Placement 1 Assemble the lag screw insertion assembly 2 Place the assembly slide the assembly over the guide pin and into the reamed hole seat the long centering sleeve in the hole to the center and stabilize the assembly 3 Insert the lag screw insert the lag screw by turning the handle clockwise until the 0 mark on the assembly aligns with the lateral cortex the threaded tip of the lag screw should lie 10 mm from the medial cortex the lag screw may be inserted an additional 5 mm in porotic bone for increased holding power 4 Remove the handle before removing the assembly, align the handle so it is in the same plane as the femoral shaft this allows proper placement of the DHS plate onto the lag screw L DHS Plate Placement 1 Place the DHS plate remove the DHS wrench and long centering sleeve slide the appropriate DHS plate onto the guide shaft /lag screw assembly loosen and remove the coupling screw and guide shaft 2 Remove the guidepin use the power drive in reverse with the Jacobs chuck attachment to withdraw the guide pin 3 Place the DHS impactor gently seat the plate with the DHS impactor the vastus ridge may be chiseled to further seat the plate on the bone 4 Fix the plate to the bone fix the DHS plate to the femur with 4.5 mm cortex screws using AO ASIF standard screw insertion technique for further intraoperative compression of the trochanteric fracture, the DHS compression screw may be inserted into the lag screw N Wound Closure 1 Irrigation and hemostasis flush out nail insertion site, lag screw, and interlocking screw sites with saline bulb irrigation cauterize peripheral bleeding vessels 2 Close the deep fascia close fascia lata and IT band with 0-vicryl 3 Close the superficial layers subcutaneous and skin closure with 2-0 vicryl and staples 4 Soft incision dressings over hip, proximal and distal femur Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care remove dressings POD 2 2 Inpatient physical therapy start range of motion exercises of the hip and knee 3 Appropriate medical management and medical consultation 4 Discharges patient appropriately pain meds outpatient PT schedule follow up appointment in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans
A Outpatient Evaluation and Management 1 Obtains focused history and performs focused exam check neurovascular status compare extremity to contralateral limb concomitant and associated orthopaedic injuries 2 Appropriately interprets basic imaging studies interpret AP pelvis and lateral radiographs of the affected hip 3 Recognition / evaluation of fragility fractures order appropriate workup and/or consult 4 Interacts with consultants regarding optimal patient management timing of surgery medical management assess risk for thromboembolic disease 5 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 6 Provides post-operative management and rehabilitation; WB status postop: 2-3 Week postoperative visit wound check diagnose and management of early complications staples/sutures removed continue physical therapy and range of motion exercises repeat xrays of femur postop: ~ 3 month postoperative visit diagnosis and management of late complications repeat xrays of femur postop: 1 year postoperative visit B Advanced Evaluation and Management 1 Comprehensive assessment of fracture patterns on imaging studies 2 Interpretation of diagnostic studies for fragility fractures with appropriate management and/or referral 3 Arranges for long term management of geriatric patients management of bone health discharge planning to long term care 4 Modifies and adjusts post-operative treatment plan as needed 5 Provides prohylaxis and manages thromboemblotic disease C Preoperative H & P 1 Perform focus orthopaedic history and physical perform careful extremity exam document distal neurovascular status identify associated injuries and comorbidities identify patient comorbidities and ASA status (predictor of mortality) screen medical studies to identify and contraindications for surgery 2 Order basic imaging studies order AP pelvis, ap and lateral of affected hip 3 Perform operative consent including lists potential complications describe complications of surgery including medical complications including death definitive stabilization within 48-72h associated with decreased pulmonary complications, thromboembolic events, length of hospital stay, and morbidity/mortality varus collapse with screw cut out AVN of the femoral head
E Preoperative Plan 1 Template intramedullary nail and cephalomedullary screws measure the size of the hip screw 2 Surgical walkthrough resident can describe key steps of the operation verbally to attending prior to beginning of case. list potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation DHS system 2 Room setup and equipment radiolucent fracture table (Jackson fracture) c-arm fluoroscopy 3 Patient positioning make sure patient has Foley urinary catheter in place patient supine with feet padded with webril and placed firmly in fracture table boots if contralateral leg dropped down, if raising contralateral leg up 90° use thigh holder padded post deep into groin, move genitals and Foley catheter out of the way ipsilateral arm on stack of blankets over chest and taped down, contralateral arm on arm board prep and drape entire leg up to iliac crest to make sure adequate working area c-arm from contralateral side at 45° towards hip take initial fluoro AP/Lat of hip to examine femoral neck mark position of C-arm to ensure proper positioning during remainder of case (~15° tilt for correct AP xray of hip) G Lateral Approach to the Hip 1 Mark and make the incision make straight lateral incision two finger breadths below the vastus ridge to a point 5-7 cm distally 2 Dissect down to the IT band perform subperiosteal dissection to sweep the subcutaneous tissue from either side of the IT band 3 Incise the fascia lata make an incision in line with the fascia lata 4 Place retractors place Charnley retractor deep to the IT band use blunt dissection between the vastus lateralis and the IT band to remove the adhesions 5 Retract the vastus lateralis anteriorly 6 Expose the bone elevate the posterior portion of the vastus lateralis off to expose bone use a periosteal elevator too bluntly split the posterior 20% of the vastus directly down to bone, and then elevate it off the bone 7 Place Benet retractors insert 2 large Bennet retractors over the anterior edge of the femur, and rest the retractor handles underneath the previously applied Charnely retractor use a periosteal elevator to strip the remaining tissue from the lateral aspect of the femur H Fracture Reduction and Guidepin Placement 1 Reduce the fracture 2 Determine the degree of anteversion determine the amount of anteversion by placing the DHS/DCS guide pin anteriorly along the femoral neck with the use of the appropriate DHS angle guide 3 Place the pin gently hammer the pin into the femoral head this anteversion pin will later allow the correct placement of the central guide pin in the center of the femoral head 4 Align the DHS angle guide align the appropriate DHS angle guide along the axis of the femoral shaft 5 Place the DHS angle guide on the femur point the guide tube toward the center of the femoral head 6 Place the guidepin it is recommended to predrill the lateral cortex with a 2.0 mm drill bit due to the density of the bone insert a DHS/DCS guide pin through the appropriate DHS angle guide this should be parallel to the anteversion pin and directed toward the center of the femoral head this point of introduction will vary with the barrel angle when the 135 degree barrel angle is used, enter the guide pin through the proximal femur approximately 2.5 cm distal to the vastus ridge I Confirm Placement of the Guidepin and Insertion of Depth Measurement 1 Confirm the placement of the guidepin use image intensification to confirm the placement of the DHS/DCS guide pin under image intensification the pin must lie along the axis of the femoral neck in both the AP and lateral views and parallel to the anteversion pin 2 Remove the anteversion pin 3 Check guidepin insertion depth slide the direct measuring device over the guide pin to determine guide pin insertion depth the calibration on the device provides a direct reading calculate the reaming depth, tapping depth and lag screw length subtract 10 mm from the reading 4 Assemble the appropriate DHS triple reamer J Reaming 1 Set and place the reamer set the reamer to the correct depth insert the DHS triple reamer into the power drive using the large quick coupling attachment slide the reamer over the guide pin to simultaneously drill for the plate/barrel junction to the preset depth when reaming into the dense bone, continuously irrigate the DHS triple reamer to prevent thermal necrosis if needed tap to the predetermined depth using the Tap Assembly tapping depth can be seen through the window in the short centering sleeve K Lag Screw Placement 1 Assemble the lag screw insertion assembly 2 Place the assembly slide the assembly over the guide pin and into the reamed hole seat the long centering sleeve in the hole to the center and stabilize the assembly 3 Insert the lag screw insert the lag screw by turning the handle clockwise until the 0 mark on the assembly aligns with the lateral cortex the threaded tip of the lag screw should lie 10 mm from the medial cortex the lag screw may be inserted an additional 5 mm in porotic bone for increased holding power 4 Remove the handle before removing the assembly, align the handle so it is in the same plane as the femoral shaft this allows proper placement of the DHS plate onto the lag screw L DHS Plate Placement 1 Place the DHS plate remove the DHS wrench and long centering sleeve slide the appropriate DHS plate onto the guide shaft /lag screw assembly loosen and remove the coupling screw and guide shaft 2 Remove the guidepin use the power drive in reverse with the Jacobs chuck attachment to withdraw the guide pin 3 Place the DHS impactor gently seat the plate with the DHS impactor the vastus ridge may be chiseled to further seat the plate on the bone 4 Fix the plate to the bone fix the DHS plate to the femur with 4.5 mm cortex screws using AO ASIF standard screw insertion technique for further intraoperative compression of the trochanteric fracture, the DHS compression screw may be inserted into the lag screw N Wound Closure 1 Irrigation and hemostasis flush out nail insertion site, lag screw, and interlocking screw sites with saline bulb irrigation cauterize peripheral bleeding vessels 2 Close the deep fascia close fascia lata and IT band with 0-vicryl 3 Close the superficial layers subcutaneous and skin closure with 2-0 vicryl and staples 4 Soft incision dressings over hip, proximal and distal femur
O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care remove dressings POD 2 2 Inpatient physical therapy start range of motion exercises of the hip and knee 3 Appropriate medical management and medical consultation 4 Discharges patient appropriately pain meds outpatient PT schedule follow up appointment in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans