# Open treatment of left slipped capital femoral epiphysis (Modified Dunn osteotomy



## daniel (Jun 8, 2017)

Would this operative report fall under CPT 27181  
Open treatment of slipped femoral epiphysis; osteotomy and internal fixation  ONLY?





Procedure Performed: 
1. Left greater trochanteric osteotomy and distalization
2. Left surgical hip dislocation (anterior capsulotomy)
3. Open treatment of left slipped capital femoral epiphysis (Modified Dunn osteotomy through a surgical hip dislocation approach for slipped capital femoral epiphysis).


Indication: 
Donald trump suffered a left hip injury 6 months ago in a car accident and had some hip pain that resolved. He denied symptoms until he fell 48 hours prior to admission and has been unable to bear weight since. The pain became unbearable and he was taken to outside ER before being transferred.  Radiographic workup demonstrated a slipped capital femoral epiphysis that appears unstable with callous formation on the metaphysis suggesting acute on chronic unstable slip. Surgical stabilization was recommended. Options were discussed including in-situ pinning and surgical hip dislocation. In addition, I consulted another pediatric orthopaedic attending and given his deformity is unstable acute on chronic surgical hip dislocation was recommended. After discussing risks and benefits of the procedure with the patient and family, they were eager to proceed. 

Operative Description: 
Patient was identified with family in preoperative holding. Laterality was marked. After verifying laterality and consent the patient was taken back to the operating room in stable condition. Patient was transferred to the operating room table and all bony prominence were padded. General anesthesia was administered by the anesthesia team. Preoperative antibiotics were given. Surgical timeout was performed, laterality was again verified and the surgical team reached a consensus. Operative extremity was drapped and prepped in sterile fashion.

An incision was marked directly overlying the tip of the greater trochanter,
extending about 1/3 proximal 2/3 distal from the tip of the greater trochanter.
Incision was carried down through skin with the use of a 10 blade. Bovie
electrocautery was used to carry the dissection down through subcutaneous
tissues, down to the level of the IT band. Self retaining retractors were used
to hold the fat and incision was then made in the IT band with use of the Bovie
electrocautery in the anterior to posterior direction, directly overlying the
tip of the greater trochanter. Once the IT band fascia was released distally, then proximally, the
interval between the gluteus maximus and medius was palpated and protected so
that only the fibers of the gluteus maximus were split.

At this point, we then cleared off the bursa underlying this and that allowed
visualization of the vastus lateralis as well as the gluteus medius. The Bovie
was used to outline the posterior aspect of the vastus lateralis.. The
muscle was dissected off the femur in an extra periosteal fashion in a more
anterior direction with use of a Hohmann retractor to provide tension for the
muscle. Once this was completed, the posterior border of the gluteus
Medius was identified and the interval between the gluteus minimus and piriformis was identified and the interval developed.

The sagittal saw was then used to perform a greater trochanteric osteotomy leaving the medius and minimus attached to the troch with the piriformis attached to the fixed trochanter.
Once this was completed, then we
were able to dissect anteriorly, elevating the minimus off the
capsule until we reached the point of the reflected head of the rectus
anteriorly. We released the reflected head of the rectus off the capsule and
then with palpation we were able to feel the entirety of the acetabular rim more
posterior as well as anterior.

We then set about with our capsulotomy. The vastus ridge was used to isolate a
good line with the femoral neck. Capsulotomy was initially performed along the
femoral neck, heading towards the acetabular rim with use of a tonsil to provide
tension on the capsule once the initial capsulotomy had been made and provide
visualization inside of the capsule to ensure that the labrum was not damaged.
This capsulotomy was carried to the labrum. It was then extended down the shaft
around the anterior portion of the femoral neck. 

We then proceeded with the posterior limb of the Z capsulotomy. This began at
the junction of the capsulotomy and labrum and was directed posterior, insuring
that we stayed out of the labrum, but heading with the capsulotomy more
posterior. With this completed, the entirety of the capsulotomy was completed and we were then able
to begin to dislocate the hip with a combination of external rotation and
flexion. It was noted at this point that the epiphysis was moving separate from
the metaphysis and therefore a threaded Steinmann pin was placed through the
metaphyseal bump into the epiphysis, and then this allowed for a combined motion
of the metaphysis with epiphysis fragment, and the hip was able to be
Dislocated. 

Prior to dislocation a 0.0625 k-wire was used to create a small hole in the epiphysis with red blood that emitted from the hole. Using the camino ICP monitor a good wave form that corresponded to pulse was seen.

In order to allow for hip dislocation once the hip was subluxed, we were able to
take curved Mayo scissors and release the ligamentum and this was removed with
use of a rongeur. We were then able to pack a lap sponge into the joint. There
were no significant chondral injuries appreciated on the acetabular portion of
the joint surface.

We then set about with our subperiosteal dissection. A 15 blade was used to
sharply incise the periosteum along the line of the neck following the initial
limb of the capsulotomy. With combination of the wood handled periosteal
elevator as well as a 15 blade, this was carried anterior as well as posterior.
Anterior releases in the periosteum were made to ensure that it would release
around the Steinmann pin that had been placed. This was released down to the
level of the lesser trochanter to ensure an adequate release. Posteriorly this
release was carried and started posterior until we were at the level of the
trochanter. A large curette was then used beginning at the physeal scar of the
greater trochanter, de-cancellating the greater trochanter so as to decompress
the greater trochanter for future repair of this periosteum once the deformity
had been corrected. After this was done ICP pressures were again checked and good waveform was seen corresponding to pulse. 

With this entire periosteal sleeve released and free, we were then able to
remove the threaded Steinmann pin, and allow for further external rotation
presenting the metaphyseal bump as well as the metaphyseal deformity to us. A
combination of a rongeur and curette were then used to remove the metaphyseal
callus, especially posteriorly, but also at the end of the metaphyseal portion
so as to allow for a small amount of shortening to allow the epiphyseal fragment
to be re-perched on top of the metaphysis without stretching the posterior blood
supply.

Once we were satisfied with this a small curette was used to ensure that any
remaining physis was removed from the epiphyseal fragment, allowing for bony
healing. We then reduced the
metaphyseal fragment back into the epiphyseal portion and a threaded
guidewire for the 6.5 cannulated screw set was placed beginning distal
to our osteotomy fragment and heading up the neck into the epiphyseal fragment
with use of a 2nd guidewire for measuring beginning at the physeal scar to
ensure that there was not joint penetration with this wire. A 2nd wire was then
placed and at this point we were satisfied with the re-creation of the proximal
femoral anatomy, however, we wanted to confirm under C-arm fluoroscopy.
Therefore, we reduced the hip and it was noted that the epiphysis and metaphysis
were moving as one segment. X-ray confirmed our observations of good re-
creation of the proximal femoral anatomy. Next, cannulated screws were placed with appropriate length and verified on fluoroscopy and approach-withdrawal.

We thoroughly irrigated the wound and #1 Vicryl was used to close the periosteal
dissection that had been performed, making sure so as not to place any suture
too far posterior due to the blood supply posterior. The periosteum was sutured
in a combination to itself as well as tacked down to the existing bone. With
this completed we were then able to reattach the osteotomy fragment, distalizing it somewhat. The 3 K-
wires were inserted and confirmed under C-arm fluoroscopy that they were heading
towards the lesser trochanter, and had a good spread on the lateral x-ray.
These K-wires were then removed and a 0.062 K-wire maintained the trajectory and
then a 3.5 cortical screw was placed in each hole.

With this completed, our final C-arm fluoroscopy shots were obtained, which
revealed good correction of the proximal femoral anatomy. We then set about
closing the remainder of the wound. The wound was again thoroughly irrigated
and then the vastus lateralis fascia was closed with use of a running 0 Vicryl.
This entire fascial sleeve, vastus lateralis to the gluteus medius, was closed.
This provided coverage of all of the screws that had been placed. The IT band
fascia was then closed with use of a running #1 Vicryl. The skin was then closed
with interrupted 2-0 Vicryl subcutaneous stitches and a 3-0 running Monocryl
subcuticular stitch. The skin was cleansed and then Prineo from Dermabond was
placed on the wound and then Telfa pads with Tegaderms. 

The drapes were then removed. The patient was laid supine on a flat plate for a


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