A Outpatient Evaluation and Management 1 Obtains focused history and performs focused exam determine the mechanism of injury check neurovascular status document presence of underlying osteoarthritis concomitant and associated orthopaedic injuries 2 Interpret basic imaging studies AP pelvis and Judet views 3 Interact with consultants regarding optimal patient management timing of surgery medical management assess risk for thromboembolic disease 4 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit wound check diagnose and management of early complications<br /> staples/sutures removed continue physical therapy and range of motion exercises postop: ~ 3 month postoperative visit diagnosis and management of late complications<br /> check for evidence of callus on the radiographs advance weightbearing to partial weightbearing start strengthening and gait training with special concentration on the hip abductors postop: 1 year postoperative visit B Advanced Evaluation and Management 1 Comprehensive assessment of fracture patterns on imaging studies 2 Modifies and adjusts post-operative treatment plan as needed 3 Provides prohylaxis and manages thromboemblotic disease C Preoperative H & P 1 Obtain history and perform physical exam document distal neurovascular status identify patient comorbidities and ASA status (predictor of mortality) make sure patient has Foley urinary catheter in place 2 Order basic imaging studies Judet Views 3 Perform operative consent and lists potential complications describe complications of surgery including postoperative arthritis superficial / deep infection heterotopic ossification
E Preoperative Plan 1 Radiographic templating of fracture check the amount of marginal impaction and fracture displacement with CT scan, AP pelvis and Judet views 2 Execute surgical walkthrough describe the steps of the procedure to the attending verbally prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation Recon plates 2 Room setup and equipment fracture table hip positioners or bean bag 3 Patient positioning prone position affected side is suspended using distal femoral traction pin peroneal post padded to prevent pudendal nerve palsy place the affected leg in traction with the hip in extension and the knee flexed to at least 80 degrees pad the foot and secure the foot to the fracture table in the resting position place SCDs on both legs bovie pad on contralateral thigh or abdomen G Kocher Langenbock Approach 1 Mark out the incision over the greater trochanter make a longitudinal incision centered over greater trochanter start just below iliac crest, lateral to PSIS extend to 10 cm below tip of greater trochanter 2 Deepen the incision starting at the lower half of the incision incise fascia lata in lower half of incision extend proximally along anterior border of gluteus maximus 3 Split the gluteus maximus split gluteus maximus muscle along avascular plane 4 Release portion of gluteal sling to aide in anterior retraction of muscle belly 5 Identify and release the short external rotators detach short external rotators after tagging the piriformis should be tagged and released approximately 1.5cm from the tip of the greater trochanter to avoid damaging the blood supply to the femoral head 6 Identify the greater sciatic notch the piriformis will provide a landmark leading to the greater sciatic notch 7 Tag structures the obturator internus should be tagged 1.5 cm from the greater trochanter and blunt dissection should be used to follow its origin to the lesser sciatic notch posterior retraction will protect the sciatic nerve 8 Expose the posterior wall clear abductors and soft tissue to visualize posterior capsule and posterior wall region H Fracture Site Exposure and Debridement 1 Debride the fracture site debride the fracture site and the joint remove any residual hematoma from the field this will make the posterior wall fragment and the posterior column easily visible 2 Inspect the posterior column carefully look for any non displaced transverse fracture lines 3 Book open the fracture site flip the wall piece out into the wound the posterior wall typically remains attached by the wall capsule and some periosteum 4 Debride the fracture site strip away from the wall any periosteum that prevents the mobilization be aware not to injure any of the labral attachments peel all the periosteum off the fracture edges direct visualization of interdigitation at the fracture site is vital in judging anatomic reduction often times it is necessary to sharply dissect the overlying gluteus minimus from the posterior wall to allow mobilization 5 Visualize the femoral head 6 Inspect the interior of the hip joint look for any damage to the femoral head 7 Remove any intra-articular fragments irrigate the joint to remove any other debris 8 Create space in the joint use the fracture table/femoral distractor to pull traction and distract the joint this will help with joint debridement 9 Prepare the intact segment in a similar fashion strip any additional periosteum and soft tissue that remains attached to the intact retroacetabular surface at the fracture edge elevate the soft tissue from the top of the ischium this prepares the ischium to receive the reconstruction plate elevate the soft tissues that are superolateral to the acetabulum on the outer table of the ilium this prepares this area to receive the proximal aspect of the place in this area it is often needed to elevate the overlying gluteus minimus I Reduction of Marginal Wall Impaction 1 Reduce areas of marginal impaction check the preoperative imaging for areas of marginal impaction when the femoral head is sitting in the acetabulum reduce the areas of impaction to the head place an osteotome deep to the depressed areas of the subchondral bone this can be done with gentle malleting this technique reduces the articular surface with intact cartilage 2 Replace the defect pack the area of original bone collapse with osteoconductive bone void filler this provides structure and prevents recollapse J Reduction of the Posterior Wall Fragment 1 Flip the wall fragment into its bed use a ball spike pusher to manipulate the piece until a smooth convex retroacetabular surface with no external stepoff is obtained if this cannot be accomplished flip the wall piece out of the bed and look for causes of malreduction if the fragment doesn’t reduce perfectly at the retroacetabular surface, it will not reduce perfectly at the joint K Provisional Fixation 1 Place interfragmentary lag screws or K wires place a ball spike pusher to stabilize the fracture fragment and place a K wire or Lag screws to hold the reduction the advantage of using 2.7 mm lag screws is that the heads sit flush with the bony cortex and do not interfere with the subsequent placement of definitive fixation 2 Place a spring plate cut the end hole of a one third tubular plate into a V thus creating tines bend the plate so that the tines can effect the reduction this plate can be used as provisional fixation to hold a small wall fragment in place or as a small spring plate to prevent the medial aspect of a large wall fragment from kicking up place the tines and a portion of the plate over the wall fragment position the plate so it is possible to drill outside of the joint L Reconstruction Plate Stabilization 1 Place reconstruction plate place a slightly underbent contoured eight hole plate that is fashioned to sit at the edge of the wall and the labrum ensure that there is no portion of the plate that is sitting on the labrum placing the plate in this location offers the greatest biomechanical advantage in buttressing the wall 2 Perform initial fixation place the initial fixation of the plate to the pelvis at the level of the ischial tuberosity drill into screw hole number 2 from the distal aspect of the plate this should be resting within the recess at the top of the ischial tuberosity aim distally and medially into the proximal portion of the ischium this area has good bone stock 3 Check position of the plate check that the plate position is at the edge of the wall but not impinging on the labrum 4 Place a ball spiker place a ball spike pusher into screw hole number 8 5 Place the proximal screw use a ball spike pusher and place the first proximal screw in hole number 7 this will compress the plate to the posterior wall 6 Remove any Kwires 7 Place additional screws place at least one additional screw proximally and one distally 8 Check imaging take C arm images to evaluate the reduction and ensure that the screws are place extra-articularly check that the joint is reduced check the proximal screws using the obturator oblique view check the distal screws with the iliac oblique view N Wound Closure 1 Irrigation, hemostasis, and drain pulsatile irrigate acetabulum and deep tissues cauterize peripheral bleeding vessels check the integrity of the sciatic nerve place a hemovac drain on the bone along the posterior aspect of the posterior wall remove any devitalized muscle to decrease the risk of heterotopic ossification 2 Deep closure repair short external rotators and capsular layer with #5 Ethibond figure of 8 sutures tie to either glut medius anteriorly or through bone on posterior aspect of GT close TFL with #1 Ethibond figure of 8 sutures 3 Superficial closure need use 3-0 vicryl for subcutaneous tissue use 3-0 nylon for skin 4 Dressing and immediate immobilization soft incision dressings over hip
O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids use antibiotics for 24 hours heterotopic ossification prevention (controversial) indomethacin 25 mg orally three times daily Radiation DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care change dressings POD2 2 Appropriate medical management and medical consultation 3 Initiate physical therapy POD1 4 out of bed the next day no active range of motion of the hip passive range of motion only footflat weightbeaing for 3 months 5 Discharges patient appropriately pain meds DVT prophylaxis schedule follow up appointment in 2weeks outpatient PT R Complex Patient Care 1 Develops unique, complex post-operative management plans