Name:
Safe Surgical Dislocation
Description:
Safe Surgical Dislocation
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/4b163a6d-c244-4855-8f94-1ca3ec19dcd5/videoscrubberimages/Scrubber_1.jpg
Duration:
T00H11M10S
Embed URL:
https://stream.cadmore.media/player/4b163a6d-c244-4855-8f94-1ca3ec19dcd5
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/4b163a6d-c244-4855-8f94-1ca3ec19dcd5/Safe surgical dislocation.mp4?sv=2019-02-02&sr=c&sig=GSvppPyHkoz0NiQugCwc9A1kkePI9uHNIW0eYGj%2BQWc%3D&st=2024-11-21T17%3A21%3A44Z&se=2024-11-21T19%3A26%3A44Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ASHOK GAVASKAR: Safe surgical dislocation for femoral head fractures, a surgical technique video. The patient presented in the surgical technique video is a 22-year-old male who sustained a motor vehicle accident and presented to us in the ER with a femoral head fracture dislocation on the right side and an associated pelvic ring injury.
ASHOK GAVASKAR: Dave was reducing the war within 6 hours of injury and was found to be stable. The post reduction CT scan however shows a displaced and comminuted femoral head fracture. The 3D image shows the fracture line extending into the weight bearing portion of the femoral head, indicating a type II Pipkin injury.
ASHOK GAVASKAR: To perform the safe surgical dislocation, the patient is placed in a lateral incubator position on a radial loosened table, which will allow use of an image intensifier from the opposite side. Two to three assistants are required to carry out the surgical procedure. The injured limb is prepped and drape free and a formal timeout is performed to identify the correct side.
ASHOK GAVASKAR: The landmarks for surgical incision include the long axis of the femoral shaft and the greater trochanter. A 20 centimeter straight incision is made centered over the greater trochanter in line with the axis of the femoral shaft. The incision is taken down to the subcutaneous tissues and the fascia over the gluteus maximus muscle, and the tensor fascia latter are exposed.
ASHOK GAVASKAR: The next step is to identify the Gibson interval between the gluteus maximus and the medius muscle. This is best done by starting the fascial incision proximate to the greater trochanter along the anterior border of the gluteus maximus muscle. Once the fascial incision is made, the muscle fibers are gently teased off from the fascia here, exposing the underlying gluteus medius muscle.
ASHOK GAVASKAR: The greater trochanter exposure can be improved by bringing the limb into extension. The trochanter bursa is then gently teased off to identify the posterior structures. The sciatic nerve lies over the {INAUDIBLE} and should be identified and isolated, When you are using a surgical dislocation for treating an acetabular fracture, but it is not required when you are using it for a femoral head fracture dislocation.
ASHOK GAVASKAR: The posterior border of the gluteus medius muscle is identified and retracted to expose the bioformist tendon and the underlying gluteus minimus muscle. The space between the gluteus minimus muscle and the bioformist tendon is developed and the gluteus minimus is gently elevated from the underlying capsule to make anterior exposure much easier.
ASHOK GAVASKAR: At this point, all the important posterior structures have been identified. The vastus lateralis muscle is then elevated to the femoral shaft for a distance of around 5 to 6 centimeters. The osteotomy line is then marked with a surgical knife. This diagram illustrates the technique of performing a trachantric osteotomy.
ASHOK GAVASKAR: The limb is brought into 20 degrees of internal rotation and the osteotomy line runs from anterior to the posterior board of the gluteus medius muscle and exits distal to the vastus lateralus origin, leaving behind the posterior fibers of the gluteus medius muscle, make sure the osteotomy does not run too medial, which can violate the blood supply to the femoral head. With a well-done osteotomy, the attachments of the short external rotators and the bioformist tendon will be intact.
ASHOK GAVASKAR: An oscillating saw is used for this purpose and the osteotomy measures around 1 to 1.5 centimeters in thickness. If the surgeon requires more stability at the osteotomy site, a straight cut can be modified into a step cut technique. Once the osteotomy is completed, the remaining four stage fibers of the gluteus medius muscle are sharply elevated.
ASHOK GAVASKAR: The osteotomised tranchantric fragment containing the insertion of gluteus medius and vastus lateralis muscle is then gently lifted off and refrected anteriorly. Spiked hohmann retractors are placed anteriorly to retract the osteotomised fragment and the limb is brought gradually into a position of flexion and external rotation to expose the anterior capsule.
ASHOK GAVASKAR: Further dissection is performed to expose the entire anterior, superior and inferior capsular region. A spiked hohmann retractor can be hammered in, into the anterior column to retract the anterior soft tissues. Now the entire anterior capsule is exposed and the capsulotomy can be done. The anterior capsulotomy, is performed in a z shaped fashion, as described by Professor Ganz.
ASHOK GAVASKAR: One hour we're asked to remember that atypical capsular tears and aversions can already be present because of the injury and you may have to modify your capsulotomy accordingly. The anterior limb of the capsulotomy is performed first. It is then taken down into the inferior capsule, which is completely released.
ASHOK GAVASKAR: When the capsulotomy is extended into the medial aspect, you have to be extremely careful not to violate the hip. Finally, the superior aspect of the capsulotomy is done. Now the capsulotomy is completed and you can see two capsular flaps as superior and inferior. The femoral head is now gently dislocated by using a bone.
ASHOK GAVASKAR: Now the fracture site is completely exposed and the fracture bed is clear of debris and clots. As you can see, the fracture is coming in turn with a supra four viola main fragment and a small comminuted accessory fragment on the inferior aspect. The acetabular cavity is inspected for presence of condral and interacticular bony fragments, which should be removed at this point.
ASHOK GAVASKAR: We should also look for associated labral avulsions which should be required if identified by using 3 millimeter suture anchors. Having ruled out labral lesions, the fracture is now reduced and held in place by using a pointed Weber clamp. Fracture reduction is checked all around, and is found to be anatomical.
ASHOK GAVASKAR: We prefer to use 2.4 millimeter counters and cortex screws for fixation. Whenever possible, we prefer to drill from the antoinferior portion of the femoral head. Brisk back bleeding from the fracture fragment indicates viability. The near cortex is slightly over drilled to help in counter sinking and a 2.4 millimeter cortex screw is inserted and countersunk.
ASHOK GAVASKAR: The communinated antoid inferior fragment is fixed using a similar technique. Fixation is completed by placing two or more screws into the main fragment. The mark made by the prongs of the Weber clamp is used to insert the final screw. The reduction of the head fragment and fixation is checked all around, and apex gently relocated.
ASHOK GAVASKAR: The anterior capsulotomy is then approximated and closed by using number one absorbable sutures in a interactive manner.
ASHOK GAVASKAR: The limb is now brought back to neutral position and the osteotomised fragment is reduced back. Production is checked and the osteotomy is provisionally secured by using two, two millimeter k-wires. We prefer to use two or 3, 3.5 millimeter fully thread cortex screws for fixation of the osteotomy.
ASHOK GAVASKAR: These screws are typically 50 to 70 millimeter in length and they get excellent purchase into the opposite medial cortex, allowing immediate mobilization of the limb. The quality of reduction of the fracture and osteotomy is checked using fluoroscopy. The hip joint is also assessed for congruency.
ASHOK GAVASKAR: You can see the posterior fibers of the gluteus medius that were left behind. The bioformis tendon and the entire posterior structures that are left intact after the surgical procedure. The wound is now closed in layers, the suction drained. Postoperatively, the patient is allowed active range of movement exercises of the hip joint but is placed on a restricted weight bearing protocol till 8 weeks. Following which is allowed uninterrupted weight bearing. Follow up
ASHOK GAVASKAR: X-rays of six months show a well healed fracture and an osteotomy with a congruent hip joint.
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