A Intermediate Evaluation and Management 1 Obtains focused history and physical, recognizes findings commonly associated with hip septic arthritis history similar to history of osteomyelitis vaccination history must be obtained symptoms presents more acutely than osteomyelitis often associated with fever and other systemic symptoms causing toxic appearance children refuse to walk or move their hip physical exam inspection and palpation localized swelling effusion, tenderness, and warmth hip rests in a position of flexion, abduction, and external rotation hip capsular volume is maximized with flexion, abduction, and external rotation and is the position of comfort for hip septic arthritis range of motion severe pain with passive motion unwillingness to move joint (pseudoparalysis) examine adjacent joints must rule out adjacent joint involvement recognizes factors that could predict complications or poor outcome 2 Orders and interprets required diagnostic studies radiographs AP and frog-leg lateral pelvic x-rays ultrasound may be helpful to identify effusion can be used to guide aspiration MRI difficult to obtain emergently identifies a joint effusion and adjacent osseous involvement must distinguish from transient synovitis 90% chance of septic arthritis if 3 out of 4 of the following are present WBC > 12,000 cells/µl inability to bear weight fever > 101.3° F (38.5° C) ESR > 40 mm/h CRP > 2.0 (mg/dl) temperature > 101.3° (38.5° C) is the best predictor of septic arthritis followed by CRP of >2.0 (mg/dl) hip aspiration 3 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 4 Postop: 2-3 Week Postoperative Visit wound check diagnose and management of early complications B Advance Evaluation and Management 1 Assimilates all diagnostic testing and makes a decision about the need for surgical drainage 2 Modifies post-operative plan based on response to treatment patient fails to improve post-operatively C Preoperative H & P 1 Obtains history and performs basic physical exam check range of motion 2 Screen medical studies to identify and contraindications for surgery 3 Orders appropriate initial imaging and laboratory studies radiographs, CRP,ESR and WBC count 4 Perform operative consent describe complications of surgery including delay in diagnosis osteonecrosis damage to the LFCN
E Preoperative Plan 1 Radiographic discussion 2 Execute a surgical walkthrough describe steps of the procedure to the attending prior to the start of the case describe potential anatomic dangers of procedure and steps to avoid them. F Room Preparation 1 Surgical instrumentation deep right angle retractors and a Cobb elevator drain or penrose catheter 2 Room setup and equipment standard OR table 3 Patient positioning 4 test supine place a bump under the ipsilateral hip to elevate it 25 degrees G Anterior Approach 1 Mark the anterior incision flex the hip 90 degrees to develop the crease draw a line that is in line with the skin crease of the anterior hip the incision should be 2cm medial and 2 cm lateral to the ASIS 2 Perform dissection perform sharp dissection through the skin and subcutaneous tissue externally rotate the leg and identify the sartorius identify the interval between the sartorius and tensor fascia lata open the interval using use Metzenbaum scissors, small blunt retractors, or a hemostat H Joint Capsule Exposure 1 Identify neurovascular structures identify the lateral femoral cutaneous nerve beneath the fascia on the lateral border of the sartorius retract the nerve medially look for the lateral femoral circumflex vessel branches at the distal portion of the interval. these branches may be coagulated without increasing risk of osteonecrosis to the femoral head identify the direct head of rectus femoris tendon tendon the direct head inserts onto the AIIS identify the indirect head at the proximal extent of the direct head lies the indirect head this will divide and travel out laterally to insert at the junction between the acetabulum and the hip joint capsule 2 Expose the joint capsule use a Cobb elevator for blunt dissection to expose this deeper layer retract the head of the rectus femoris muscle medially this exposes the capsular iliacus and deep capsule of the hip joint use a cobb or peanut retractor and remove any remaining soft tissue from the capsule I Arthrotomy 1 Create arthrotomy window use sharp dissection to remove a square window of capsule window can vary in size but typically 1 to 2 cm J Cultures 1 Take aerobic and anaerobic cultures include two samples for Gram stain and cell count K Irrigation and Stability Assessment 1 Copious irrigate the hip joint irrigate the joint until all purulent material has been removed 2 Check the stability of the joint assess the stability of the joint by placing the hip in extreme positions of abduction and extension L Drain Placement and Wound Closure 1 Place penrose drain 2 Close superficial layers with absorbable suture 3 Place soft dressings
O Perioperative Inpatient Management 1 Write comprehensive admission orders advance diet as tolerated IV fluids inpatient occupational and physical therapy weight bear as tolerated IV antibiotics pain control wound management remove dressings POD2 check appropriate labs WBC, ESR and CRP 2 Appropriate medical management and medical consultation consult infectious disease 3 Discharges patient appropriately pain control oral antibiotics schedule follow up in 2 weeks wound care R Complex Patient Care 1 Modifies post-operative plan based on response to treatment patient fails to improve post-operatively 2 Able to develop a comprehensive preoperative plan that includes options based on intraoperative findings managing dislocated hip