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
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
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