Surgical Techniques

Hip Arthrogram

 

Technique

- under II

- 10 mls contrast mixed with 10 mls saline

- prime the line

- spinal needle

- do not spill contrast over front of hip as will obstruct view

 

A. Lateral approach

- 45° angle with thigh

- insert just inferior & anterior to the greater trochanter

- advance 5-10 cm

- enter joint medially

 

B.  Anterior approach 

- preferred technique

- palpate femoral artery just below inguinal ligament

- femoral head is halfway between ASIS and pubic tubercle

- insert needle 2.5 cm below ASIS, aim to go behind NV bundle

- at 45° angle to skin

- aim for anterior neck

 

C.  Medial approach 

- MUA & arthrogram in young child

- excess extra-articular contrast will pool inferior & medial to joint so not to obstruct view of joint

- flex & abduct leg

- insert needle inferior to adductor longus tendon

- use II

- advance below femoral artery to head or neck

- generally inferior aspect of neck just below head

 

Open reduction via Smith-Peterson approach

 

Disadvantage

- damage LFCN

- stiffness (large dissection)

- access to inferior capsule and transverse ligament difficult

 

Advantage

- reduced risk of AVN

- can perform pelvic osteotomy through approach

 

Technique

 

Incision

- use bikini incision modification

- start 3cm below ASIS

- parallel to inguinal ligament 7cm

- longitudinal causes excess scarring, especially in young girl

 

Superficial dissection

- interval between sartorius & TFL

- LFCN retracted medially on top of sartorius

- ascending branch LCFA tied off in interval

- superior plane continued proximally by splitting apophysis 

- if needed to perform pelvic osteotomy

- peel glutei off llium to expose supra-acetabular region

 

Deep dissection

- between G medius and RF

- both heads rectus divided

- reflected head blends with capsule and superior rim acetabulum

- straight head to AIIS

 

Release

- psoas released under iliacus

- careful capsulotomy at acetabular edge

- remove capsule off lateral acetabulum

- to medial corner under direct vision

- any blocks to reduction removed

- excision of ligamentum teres

- transverse ligament division

- pulvinar removed

- evert inverted labrum 

 

Gentle reduction of head

 

Tight capsulorrhaphy performed 

- especially superiorly to remove lax capsule

 

Pelvic osteotomy

- if over 1 year of age with dysplasia

- redirectional or reshaping

 

Femoral osteotomy 

- performed if excessive traction at time of reduction

- avoid AVN

 

Spica cast applied

 

Medial Open Reduction

 

Disadvantage

- risk of AVN via MCFA damage

- only < 1 year as no access to periacetabular region

- unable to perform capsulorraphy

 

Advantage

- easy access to blocks to reduction

- especially psoas / inferior capsule

- reduced blood loss

 

Technique

 

Position

- supine

- hip abducted & flexed / frog legs

 

Landmarks 

- adductor longus & pubic tubercle

 

Incision 

- parallel to & 1cm below groin crease

- over adductor longus

 

Superficial dissection

- between gracilis / posterior & adductor longus / anterior

 

Deep dissection

- between adductor magnus & adductor brevis

- protect anterior branch obturator nerve on brevis

- protect posterior branch obturator nerve on magnus

- retract adductor brevis anteriorly

- will expose lesser tuberosity with psoas tendon inserting onto it

- isolate psoas tendon before division

 

Dangers

- protect MCFA as it passes between adductor brevis & psoas at LT

- runs around the medial side of psoas / anterior to psoas tendon

- fully isolate psoas before dividing

 

Release

- release psoas at LT

- T Capsulotomy

- divide transverse Lligament

- ligamentum teres can be used to pull head into acetabulum

- suture to anteromedial capsule

- may need to place radial splits in limbus 

 

Salter Osteotomy

 

Redirectional

- corrects anterior and superolateral acetabular deficiency

- less than 5 years but > 18/12

- mild - moderate dysplasia

- need concentric reduction

 

Technique

- Smith Peterson approach

- iliac apophysis split

- subperiosteal dissection to sciatic notch reflecting gluteals

- Gigli saw - osteotomy through GS notch

- emerge anteriorly between ASIS and AIIS

- acetabulum rotated anteriorly and laterally

- triangular graft from crest

- K wire fixation

 

Complication

- 25% leg lengthening

 

Periacetabular osteotomy

 

Dega 

- leaves posterior wall intact

- relies on plasticity of superior acetabulum

 

Pemberton

- osteotomy includes posterior column

- bend through tri-radiate cartilage

 

Smith - Petersen approach

- split apophysis

- curved osteotome

- parallel superior dome of acetabulum

- 15 mm above

- can leave posterior column intact

- bone graft +/- K wires

 

Femoral Derotaton and Varising Osteotomy

 

Technique Antero-lateral 

 

Open reduction as above

 

Separate lateral approach

- elevate vas lateralis

- 2 x K wires centrally in neck, short of physis

- check II

- open and protect periosteum with homans

- mark distal and proximal femur with drill holes to check rotation later

- osteotomy with microsagittal saw 1 cm below LT

- don't need to resect wedge with Synthes offset locking plate

- may need to shorten

- decrease anteversion by IR distal fragment

- check range of ER of hip / should be reduced

 

Osteotomy fixed Synthes Offset Locking Plate

- 125o for some varus