Bernese Periacetabular Osteotomy for Hip Dysplasia in Young Adults

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Home Study Program BERNESE PERIACETABULAR OSTEoTolllly FOR HIP DVSPlASlA IN YOUNG ADULTS

he article “Bernese periacetabular osteotomy for hip dysplasia in young adults” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, education program professional, Center for Perioperative Education. A minimum score of 70% on the multiple-choice examination is necessary to earn 2.5 contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is April 30, 2005. Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 8023 1-571 1 or fax the information with a credit card number to (303) 750-3212.

BEHAVIORAL OBJECTIVES

After reading and studying the article on Bernese periacetabular osteotomy (PAO), the nurse will be able to (1) identify the anatomy pertinent to developmental dysplasia of the hip in the young adult, (2) discuss the preoperative care of the young adult undergoing Bemese PAO, ( 3 ) explain the penoperative nursing care of the young adult undergoing Bemese PAO, (4) describe the surgical steps of the Bemese PA0 procedure, and (5) discuss the postoperative course of the young adult recovering from Bemese PAO. This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

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Bernese Periacetabular Osteotomy for Hip Dysplasia in Young Adults

T 1

The acetabulum is a hemispherical socket formed in the 0s coxae (ie, bony pelvis) of a newborn where the ilium, ischium, and pubis bones come together. The acetabular labrum (ie, a rim of fibrocartilage) helps increase the depth of the acetabulum. Pelvic nervous innervation. The first through fourth lumbar nerves combine to form the lumbar plexus, which lies in the posterior portion of the psoas muscle. The femoral, lateral cutaneous, and obturator nerves exit from the lumbar plexus. The femoral nerve is located on the anteromedial side of the iliopsoas muscle and passes under the inguinal ligament as it enters the thigh. The lateral cutaneous nerve lies along the sartorius muscle. The obturator nerve is located in the fascia directly under the pubic bone. Lumbar nerves four and five and sacral nerves one through three combine to form the sacral plexus. ANATOMY The sacral plexus lies in the middle portion of the The hip is an enarthrosis (ie, ball and socket) false pelvis. The sciatic nerve is one of the three joint. Normal hip range of motion includes abduction, major branches of the sacral plexus. As a result of this adduction, circumduction, extension, and flexion. anatomy, hip surgery increases the risk for femoral or sciatic nerve injury. Pelvic vasculature. The abA B S T R A C T dominal aorta divides at the fourth Hip dysplasia is one of the most common disorders of the hip, lumbar vertebra into the right and presenting in the first three years of life. Literature has shown that an left common iliac arteries, which association exists between developmental dysplasia of the hip and diverge and descend lateral to the the development of secondary hip osteoarthritis in early adulthood. common iliac veins and slightly Treatment options are directed toward relieving symptoms and delay- posterior and medial to the coming or preventing the onset of arthritis in the affected hip. Total hip mon iliac veins. The common iliac arthroplasty is a surgical option, but has been associated with a high arteries follow the medial border rate of failure in younger, physically active patients. This article dis- of the psoas major muscle, cusses the Bernese periacetabular osteotomy procedure as a treat- approximately 5 cm from the ment modality, which restores coverage of the femoral head with the pelvic brim. At the pelvic brim, acetabulum. Changing the anatomy allows the surgeon to increase the common iliac artery divides the surface area of the femoral head that bears the patient's weight. into the internal and external iliac Increasing the weight-bearing surface may prevent further damage to arteries. The internal iliac artery the hip's cartilage and delay the onset of osteoarthritis. AORN J 75 (ie, hypogastric) enters the pelvis and supplies the psoas major and (April 2002) 737-751. he term dysplasia describes abnormal development of tissue. Developmental dysplasia or dislocation of the hip (DDH), previously known as congenital hip dysplasia, is one of the most common hip disorders that presents in the first three years of life.' The incidence of hip dysplasia is 1 to 1.2 in 1,000 live births2 In the United States, approximately 38,900 to 46,600 babies are affected each year.' An association has been shown to exist between DDH and the development of secondary hip osteoarthrosis in early adulthood. As many as 48% of patients who require a total hip arthroplasty for degenerative joint disease have DDH as the underlying diagnosis. If left untreated, 25% to 50% of people affected with DDH may suffer from osteoarthritis by age 50.4

CR.4IG A. CiII.I.ETT, R N

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quadratus lumborum muscles, the pelvic viscera, and parts of the bony pelvis. The external iliac artery continues to follow the iliopsoas muscle, first medially, then anteriorly. It exits the pelvis under the inguinal ligament. The external iliac artery becomes the femoral artery as it leaves the pelvis. The space between the inguinal ligament and the coxal bone is divided by the iliopectineal arch. The lacuna musculorum, which is lateral to the iliopectineal arch, contains the iliopsoas muscle and femoral nerve. The lacuna vasorum, which is medial to the iliopectineal arch, contains the femoral artery and vein. The acetabulum receives its blood supply from branches of the superior and inferior gluteal arteries, the pudendal artery, and the obturator anastomoses, all of which are branches of the internal iliac artery. The anatomical location of the pelvic blood vessels puts them at risk for injury during hip surgery.

patient’s side and away from the body (ie, lateralized). A lack of joint congruity leads to a decrease in the weight-bearing surface area of the joint.” This decrease in surface area increases contact pressures. The abnormal hip structures and increased contact pressures are believed to cause a breakdown of cartilage, resulting in osteoarthritis. The etiology of DDH is not understood completely. Theories regarding its cause include mechanical factors, hormone-induced joint laxity, primary acetabular dysplasia. intrauterine crowding, and genetic inheritance. Developmental hip dysplasia has some common risk factors, including heredity, female gender, breech presentation birth, and ethnic background (Table l).’

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SIGNS, SYMPTOMS, AND EVALUATION PATHOPIIYSIOLOGY

Developmental hip dysplasia rarely involves a single component of the hip. In adolescents and young adults, DDH can range from minimal deformity of the acetabulum and proximal femur to severe articular joint incongruity. The majority of patients with DDH, however, primarily have an abnormality on the acetabular side of the joints The acetabulum is shallow or flat and may be obliquely angled. Typically, the superior and anterior coverage of the femoral head is deficient because the roof does not develop normally. This results in a hip joint whose center of rotation has moved out to the

Table 1 RISK FACTORS FOR DEVELOPMENTAL HIP DYSPIASIA (DDH)

Breech presentation birth Ethnic backaround ., (ie. . . Native American, LaDlander) I

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Female gender (ie, girls have 3 to 4 times greater chance than boys and have their left leg more commonly involved than their right) Lower limb deformity Metatarsus adductus Positive family history of oligohydramnios (ie, 10% to 36% greater chance if one parent had DDH ) Torticollis

Clinical presentation varies according to the patient’s age and stage of disease in the affected hip. In an adolescent or young adult, early symptoms of DDH include poor exercise tolerance with muscle pain secondary to muscle fatigue of the hip’s abductor muscles. Subluxation of the femoral head also may lead to pain. The pain may be in the groin, buttocks, anterior thigh, or over the area of the greater trochanter. The patient may have pain related to activity and experience difficulty performing activities of daily living.8Physical signs may include restricted range of motion in the affected hip, alimp, pelvic obliquity, or leg length di~crepancy.~ Examination of the patient should include a neurovascular examination of both legs, palpation of soft tissues and bony prominences, evaluation of gait, Trendelenburg’s test, assessment of range of motion, and assessment of leg length. The Trendelenburg’stest helps detect hip dislocations. The patient is observed from behind & he or she balances first on one foot then the other to see if there is any asymmetry of the iliac crests. In a positive Trendelenburg’s test, the iliac crest on the side opposite the weight-bearing leg will drop; the weight-bearing leg is the defective hip. An apprehension test can be performed by having the patient lie supine with the affected leg hanging over the end of the examination bed. The unaffected hip is flexed, and the leg is held by the patient. The examiner passively rotates the affected hip externally and 738

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hyperextends it simultaneously. (Figure 1). In a dysplastic hip, this maneuver forces the femoral head anterolaterally (ie, forward and to the side), leading to subluxation of the hip and subsequent groin pain.'O The patient should have x-rays taken of his or her hips to include an anterior-posterior (AP) view, a false profile, and functional radiographs of the hip in abduction and adduction without external rotation. Some surgeons may order a computed tomography scan to help determine acetabular positioning or a magnetic resonance imaging scan to look for pathology of the acetabular labrum." HISTORY

ment is to prevent osteoarthritis in these patients. Redirecting the acetabulum is the most acceptable physiological solution because it optimizes the articular congruency in the joint, increases the containment and coverage of the femoral head, and increases the surface contact area on the weightbearing surface. The Bemese periacetabular osteotomy (PAO) procedure was developed in 1983 by Reinhold Ganz, MD, Jeffrey Mast, MD, and others in Bern, Switzerland. The procedure was first described in 1988.16A Bernese PA0 allows the surgeon to move the acetabulum freely in any direction (ie, anteriorly, laterally, medially) as necessary to obtain the best coverage (Figure 2). Literature suggests that improving congruency and decreasing articular pressure by increasing articular surface contact area can halt destruction of the joint.!' The Bemese PA0 has numerous advantages over other surgical options. This procedure allows for a large correction in the coverage and containment of the femoral head; is performed through one incision; does not remarkably alter the shape of the pelvis; allows future vaginal delivery in women of childbearing age; keeps the posterior column of the pelvis intact, which allows for early ambuiation; ensures that the vascular supply to the acetabulum remains uninterrupted;

When patients present with symptomatic DDH, articular deformity usually exists. Patients may start with conservative nonsurgical management, such as use of a cane and nonsteroidal anti-inflammatory and analgesic medications and modification of activities. If the hip is not treated structurally, however, the DDH may progress to osteoarthritis.12 Surgery, therefore, has been the treatment of choice for DDH since the late 1800s." Historically, the surgical treatment options for DDH in young adults have included various (ie, single, double, triple) innominate bone osteotomies; medial displacement osteotomy; osteotomy of the proximal femur; shelf arthroplasty; rotational acetabular osteotomies; and arthrodesis of the joint.14 Although total hip arthroplasty is a surgical option, it has been associated with a high rate of failure in younger, physically active patients. Both cemented and noncemented prostheses have shown relatively poor survivor rates in young patients." Patients with DDH are at a high risk for developing early osteoarthritis because the weight supported by the hip joint is concentrated over a smaller surface area when the femoral Figure 1 * Demonstration of a positive apprehension test causing groin head subluxates up over the rim of pain in a patient with a dysplastic hip. (///usfrufion by Murk Kufnik, the acetabulum. The goal of treat- Denver) 739 AORN JOURNAL

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allows the surgeon to examine the acetabular labrum and repair it, if needed, through the same incision; and does not compromise conversion to a total hip arthroplasty, if necessary.'n Contraindications for this procedure include severe degenerative joint disease or being age 65 or older with severely limited range of motion in the affected hip.'" Fortunately, patients with DDH most often are otherwise healthy adolescents and young adults; however, it is difficult for these patients to reduce their activity levels or change their lifestyle. Reducing activity levels or making changes in lifestyle may relieve the symptoms of DDH, but the anatomy is not altered; therefore, the underlying problem remains, making this procedure the most viable treatment option. PREOPERATIVE PERIOD

The surgeon, patient, and family members discuss the proposed surgery during an office visit approximately one week before surgery. The surgeon reviews the procedure, benefits, risks, possible complications, location of incision, postoperative pain management, postoperative care, length of hospitalization, normal activities, and return to work. The surgeon obtains the patient's consent for surgery. Diagnostic and laboratory tests and x-rays are obtained. The RN first assistant (RNFA) performs a preoperative patient assessment and reinforces the surgeon's instructions. He or she discusses postoperative home health needs with the patient and family

Figure 2 Anterior view of pelvic hip with Bernese periacetabular osteotomies shown in bold lines. Arrows indicate how acetabular fragment can be moved to improve femoral head coverage. ~///~~frufioff by Murk Kutnik, Denver)

members and provides them with educational materials. The RNFA explains that members from the physical therapy (PT) and occupational therapy (OT) departments will instruct the patient on postoperative ambulation and provide tools to assist with activities of daily living during recovery. Finally, the RNFA instructs the patient when to arrive at the hospital for surgery and discusses preoperative medications and NPO status. DAY OF SURGERY

On the day of surgery, the patient reports to the preoperative holding area where the preoperative holding area nurse performs a nursing assessment. He or she measures, evaluates, and documents the patient's baseline vital signs; skin integrity and condition; color, warmth, and sensation of both lower extremities; and presence and quality of pedal pulses bilaterally. The nurse then puts thigh-high antiembolism stockings on the patient. The preoperative holding area nurse ensures that the patient is in a quiet, warm, and private area to facilitate the patient interview. The nurse asks the patient about NF'O status, loose teeth, jewelry (eg, body piercing), and present state of health. He or she reviews the preoperative laboratory values and reports abnormal values to the surgeon and anesthesia care provider. The nurse ensures that the patient's health history and x-rays are available for the surgeon. The nurse then discusses postoperative pain management with the patient. In the OR, the circulating nurse helps the scrub person gather the special instruments, equipment, and supplies needed for the procedure. The circulating nurse checks the electrosurgical unit (ESU), lights, and other equipment for proper functioning. He or she then checks the OR bed for safety straps, positioning aids, and pads. The circulating nurse notifies the radiology technician and, if the surgeon chooses to have intraoperative electromyography (EMG) monitoring, the EMG technician that the OR is ready. Finally, one of the OR team members brings portable x-ray shielding into the room. The circulating nurse goes to the preoperative holding area, greets the patient, and introduces the other OR team members. The circulating nurse interviews the patient and verifies the patient's name both verbally and with the patient's identification

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bracelet. The circulating nurse also has the patient verify the planned surgical procedure, correct hip, presence of allergies, NPO status, his or her understanding of the surgical procedure, and that consent for surgery was obtained. If the patient is unable to verify his or her name or other data, a family member or interpreter. if necessary, may be asked to confirm necessary information. The circulating nurse reviews with the patient the estimated length of the surgical procedure, time he or she will spend in the postanesthesia care unit (PACU), and methods OR team members will use to communicate with the patient’s family members during surgery. The- circulating nurse prepares a nursing care plan specific for a patient undergoing the Bemese PA0 (Table 2).>” He or she discusses the nursing diagnoses, plan of care, and expected patient outcomes with the patient. The nurse then documents this in the patient’s record. INTRAOPERATIVE CARE

The circulating nurse and the scrub person verify the sterility of instruments, equipment, and supplies. Cooperatively, they perform counts according to their institution’s policy and procedure. The circulating nurse and anesthesia care provider transport the patient to the OR and help him or her move onto the OR bed. The circulating nurse positions the patient supine and secures the safety straps. He or she places warm sheets over the patient and ensures that the patient is comfortable and warm. The circulating nurse assists the anesthesia care provider as necessary by securing the patient’s arms to the arm boards, starting an IV line, padding the patient’s pressure points, placing an upper body temperature-regulating blanket on the patient, and ensuring that the room is quiet with minimal stimuli during induction. The circulating nurse monitors the OR environment throughout the procedure and keeps OR traffic to a minimum. After induction of general, spinal, or epidural anesthesia, the circulating nurse places a Foley catheter into the patient’s bladder and provides the anesthesia care provider with a container to monitor urine output throughout the procedure. The circulating nurse places the ESU dispersive pad on the patient’s nonsurgical thigh. The EMG technician attaches 12 wire leads to the patient’s surgical leg. The leads are introduced into the patient’s muscles via a small gauge hollow-bore needle. The EMG

technician places two leads each into the vastus lateralis and the vastus medialis muscles to monitor the femoral nerve. He or she places two leads into the anterior tibialis and two into the peroneus longus to monitor the sciatic nerve. The EMG technician places the last four leads into the gastrocnemius, with two into the lateral head and two into the medial head. The leads are placed below the surgical area and do not interfere with preparation of the surgical site. The leads, however, are attached to the EMG monitor cords that connect to the EMG monitor and need to be draped in a sterile manner. This can be accomplished by passing the cords through a sterile arthroscopic camera cord sleeve. The circulating nurse preps the surgical area from just below the breasts to midthigh and from 2 cm lateral of midline on the nonsurgical side to table level on the surgical side. The surgeon, RNFA, and scrub person drape the patient with the surgical leg exposed (Figure 3). This allows mobility during surgery because the surgical leg is flexed, extended, abducted, and adducted during surgery. Blood lost intraoperatively is collected using an autologous blood salvage system and given back to the patient during the procedure or postoperatively in the PACU. During the procedure, the RNFA assists the surgeon by providing exposure and abducting and adducting the surgical leg. Procedure. The surgeons at Rochester Methodist Hospital and St Mary’s Hospital, Rochester, Minn, use a modified Smith-Peterson approach for this pelvic surgery. The surgeon makes an anterior skin incision, starting approximately 6 cm to 8 cm proximal to the anterior-superior iliac spine. The incision follows the iliac crest over the anterior spine and curves distally and laterally to end approximately 3 cm anterior and distal to the greater trochanter. The surgeon abducts the hip and develops a plane between the sartorius and tensor fascia lata muscles while protecting the lateral femoral cutaneous nerve. The surgeon continues the interval between the two muscles distally to the level of the lateral-femoral circumflex artery. The surgeon then releases the origin of the sartorius tendon from the anterior superior iliac spine, tags it with a suture to identify it for later repair, and retracts it medially. The surgeon flexes and adducts the hip and uses a periosteal elevator to strip the muscle from the inner aspect of the pelvis. He or she then removes the rectus origin from the anteriorinferior iliac spine and places a curved retractor into

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Table 2 NURSING CARE PLAN FOR PATIENTS UNDERGOING BERNESE PERIACECABUIAR OSlEOTOMV

Nursing diagnosis Risk for infection related to length of procedure and tissue manipulation during procedure.

Intervention Assesses patient preoperatively for susceptibility to infection (eg, chronic diseases, weight, laboratory values, Preoperative skin integrity). Implements, monitors, and maintains aseptic technique. Administers prescribed antibiotic therapy at appropriate times.

Interim outcome criteria Patient's skin remains intact and nonreddened, wound is dry, and temperature remains normathermic.

Outcome statement The patient is free from signs and symptoms of infection.

Initiates traffic control Helps minimize length of the intraoperative phase of surgery by planning and anticipating care. Protects patient from cross infection. Assesses risk for inadvertent hypothermia Monitors and maintains patient's body temperature Administers care to wound sites

Risk far fluid volume deficit related to anticipated blood loss

Applies sterile, dry surgical dressing after wound closure. Establishes and maintains peripheral IV access. a

Patient's vital and Oxygen signs Identifies factors associated with an increased risk for saturation levels hemorrhage. remain within Administers IV fluids and blood products as ordered. expected values,

The patient has wound/tissue perfusion consistent with or improved from baseline levels,

Reports abnormal Preoperative blood coagulation values.

Risk for urinary retention related to length of operative procedure and epidura1 medications Risk for injury due to Position'ng and intraoPerative manipulation of the operative leg

Collaborates with anesthesia care provider and surgeon to monitor intake/output and implement prescribed treatments (eg, IV fluids, autotransfusion, blood products, medications). Assesses renal status preoperatively (eg, renal function studies, urinalysis, health history). Inserts urinary catheter per surgeon's order. Monitors and measures urinary output.

Patient is free of symptoms of edema or fluid overload.

The patient's function and senAssesses the patient preoperatively for risks of inadesation is mainquate tissue perfusion (eg, chronic diseases, tained or improved immunospressian). from baseline Assesses preoperative neurovascular status of both levels. lower extremities. The patient's pedal Positions the patient neutrally and anatomically pulses are correct and pads pressure points. present and equal bilaterally. Evaluates for signs and symptoms of positioning injury by comparing patient's bilateral lower extremity neurovascular status with preoperative status and checks for signs and symptoms of injury as a result of positioning. Identifies baseline tissue perfusion.

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The patient's fluid and electrolyte balance is maintained or improved from baseline levels The patient is free from signs and symptoms of injury related to positioning.

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the greater sciatic notch. This provides excellent hip and pelvic exposure. The abductors are left unviolated at the outer aspect of the ilium. After further dissection, the surgeon exposes the pubic bone and identifies the ischium by palpation. The surgeon osteotomizes the ischium, pubis, and ilium, in that order, to free the acetabulum from the pelvis. Fluoroscopy may be used during this stage of the procedure to visualize the osteotomies. The surgeon flexes the patient’s hip and adducts it before using a pelvic osteotomy chisel to osteotomize the ischium (Figure 4). The surgeon then osteotomizes the pubic bone and divides it using a straight 12 mm to 16 mm osteotome (Figure 5). The surgeon osteotomizes the ilium in two steps. First, the surgeon uses an oscillating saw to cut the ilium to approximately 1 cm above the proximal rim of the true pelvis. The surgeon then flexes and internally rotates the patient’s hip. Second, the surgeon uses straight and curved osteotomes to cut the bone parallel to the acetabulum’s posterior column (Figures 6 and 7). The surgeon places a Schanz screw into the iliac spine of the acetabular fragment, which acts as a “joystick,” allowing the surgeon to attain the desired correction of the acetabulum. The surgeon places two or three 3.2 mm Kirschner wires (Kwires) to stabilize the fragment and obtains an AP pelvic x-ray. When the surgeon is satisfied with the correction, two to three long 4.5 mm cortical screws are used to secure the fragment (Figure 8). The surgeon removes the Schanz screw and K-wires and reattaches the rectus femoris and the sartorius tendon to the anterior-superior iliac spine. The surgeon drills five to six small holes into the outer aspect of the ilium, passes a nonabsorbable # 1 suture through these holes, and repairs the tensor fascia lata origin. The surgeon closes the wound over two 10-Fr round drains using absorbable #O suture for the deep layers and 2-0 for the subcuticular layer. The surgeon places two drains, one deep along the intrapelvic wall and one just under the subcutaneous fat layer. The drains exit through puncture wounds 2 cm to 3 cm distal to the surgical incision on the anterolatera1 side of the leg. The drains are connected together using a Y-connector that is attached to a single, disposable suction device. The drains usually remain in place until the morning of the first postoperative day. The surgeon closes the wound using absorbable #O suture for the deep layers and 2-0 for the subcuticular layer. The surgeon then closes the skin with a running 3-0 absorbable suture and applies a sterile dressing. The OR team members move the patient to a hospital bed with an over-bed frame and trapeze and transport the patient to the PACU.”

Figure 3 Surgical leg draped free for intraoperative manipulation.

Figure 4 Osteotomy of the ischium. (///ustrationby Mark Katnik, Denver)

Figure 5 Osteotomy of the pubis. (///ustrationby Mark Katnik, Denver)

POSTOPERATIVE RECOVERY

The circulating nurse gives report to the PACU nurse, including patient history, the surgical procedure, and all significant intraoperative events. The PACU nurse assesses and monitors the patient’s dressing, vital signs, oxygen saturation, and urine output. The PACU nurse also assesses the patient for 745

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criteria, the PACU nurse calls report to the postoperative surgical nursing care unit and transfers the patient in his or her bed. RISKS AND COMPLICATIONS

Figure 6

Complications of the Bemese PA0 procedure include intra-articular extension of the iliac osteotomy into the acetabulum, extension of the osteotomy through the posterior column of the ileum, over or undercorrection of the acetabular fragment, hematoma, wound infection, nonunion of bone at the osteotomy sites, deep vein thrombosis (DVT), heterotopic ossification, and pain at the site of hardware placement. Risks of the Bernese PA0 procedure include damage to the sciatic, femoral, or obturator nerves and injury of a major blood vessel.2’

First step in the osteotomy of the ilium.

(Illustration by Mark Katnik, Denver)

EDUCATION AND DISCHARGE PLANNING

Figure 7 Second step in the osteotomy of the ilium. Note the Schanz screw placed in the acetabular fragment. (//lustrationby Mark Katnik, Denver)

pain; headaches; nausea and vomiting; and changes from the patient’s preoperative baseline color, warmth, and sensation of both lower extremities and presence/quality of bilateral pedal pulses. An x-ray is taken postoperatively to verify that the acetabulum is corrected and the acetabular fragment is secured with cortical screws (Figure 9). The PACU nurse regulates the patient’s IV line, administers pain medications, and documents the patient’s response to pain management interventions. Postoperative pain management may include an epidural catheter connected to a patient-controlled analgesia pump. Postoperative epidural anesthetic agents, such as lidocaine, should not be used because they may mask nerve injury that occurred intraoperatively.Use a narcotic epidural medication instead. The epidural catheter usually remains in place one to three days postoperatively. When the patient meets discharge

Postoperatively, the RNFA visits the patient to assess and document the patient’s wound and the success of implemented pain management interventions. The RNFA performs a neurovascular examination of both lower extremities, checking for signs and symptoms of DVT or other postoperative complications. The RNFA reviews and reinforces patient and family member education, including recommended pain medications and wound care. The RNFA ensures that the patient’s PT and OT appointments and follow-up postoperative visits to the surgeon have been scheduled. When the patient is ready for discharge, the RNFA discusses and reviews discharge care with the patient and family members, including follow-up appointments with the surgeon; goals of PT and OT appointments; how to prepare for the recovery period and make necessary home modifications; pain management to include obtaining pain medication prescriptions; restrictions on activities of daily living; return to work; and wound care. Finally, the RNFA assesses and documents the patient’s and family members’ understanding of instructions to improve compliance.23

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ally. He assessed and documented the color, warmth, Mrs P is a married, 27-year-old woman with two movement, and sensation of both lower extremities preschool-aged children at home. She is employed as and the quality of Mrs P’s pedal pulses bilaterally. a cashier at a large retail store, and her husband The anesthesia care provider and circulating works as an over-the-road truck driver. nurse transferred Mrs P to the OR via stretcher and At the time of Mrs P’s first visit with the sur- helped her move to the OR bed. The circulating geon, her medical history revealed that she had Type nurse secured the safety strap and introduced Mrs P 1 insulin-dependent diabetes mellitus (IDDM) and to the OR staff members. After the anesthesia care that both she and her husband smoked. The surgeon provider initiated all anesthesia monitoring devices, and RNFA counseled the patient and her husband she inserted an epidural catheter to be used for postregarding their smoking status. Both Mr and Mrs P operative pain management. The anesthesia care agreed to try to stop smoking. provider induced general anesthesia and then placed Additionally, the surgeon, RNFA, and a regis- a temperature-regulating blanket across Mrs P’s tered dietitian counseled Mrs P regarding her IDDM. upper body. The anesthesia care provider initiated They reviewed Mrs P’s diet, exercise, and ability to blood glucose monitoring, which she continued perform home blood glucose monitoring. At the time throughout the procedure. The circulating nurse of surgery, Mrs P was independently performing blood glucose monitoring three times per day before each meal and was averaging a blood glucose level of 131 mg per dL. The surgeon ordered preoperative blood laboratory work to include a blood glucose level. Mrs P’s preoperative fasting blood glucose level was 127 mg per dL. Mrs P and her husband arranged for their parents to provide three weeks postoperative help with Mrs P’s activities of daily living and child care. Mrs P arrived at the hospital on the day of surgery and after being admitted to the hospital, she was escorted to the preoperative holding area. The preoperative holding Figure 8 Anterior view of the fixation of the acetabuarea nurse placed an IV line and administered a dose lar fragment with cortical screws. (///ustrutionby Murk Karnik, Denver) of antibiotic, as ordered by the surgeon. The anesthesia care provider and circulating nurse interviewed Mrs P, verifying the planned surgical procedure and correct surgical side. After reviewing Mrs P’s medical record, they discussed Mrs P’s current smoking status. Mrs P explained that she had attended a smoking cessation class, as agreed, and had begun using a nicotine patch in consultation with the surgeon and her family physician. Mrs P reported that she had successfully decreased her smoking from one to one and onehalf packs per day to three to four cigarettes per day. The circulating nurse assessed Mrs P’s skin integrity by visual inspection and Figure 9 Preoperative and postoperative anterior pelvic x-rays of a palpated her pedal pulses bilater- Bernese periacetabular osteotomy. CASE STUDY

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inserted a Foley catheter and placed an ESU dispersive pad on Mrs P’s nonsurgical thigh. After the circulating nurse prepped Mrs P’s surgical leg, the surgeon, RNFA, and scrub person draped Mrs P, and the surgeon made the incision. An intraoperative blood salvage device was used to collect, filter, and reinfuse the patient’s blood intraoperatively. Fluoroscopy was used during the osteotomies, after which an AP pelvic x-ray was taken to verify acetabular correction and the position of the three screws used to fixate the acetabular fragment to the pelvis. The surgeon placed two drains in the surgical incision, closed the wound, and applied a sterile wound dressing. The anesthesia care provider and circulating nurse transferred Mrs P to the PACU and gave report to the PACU nurse. The circulating nurse noted that there were no changes in Mrs P’s skin integrity or pedal pulses bilaterally. The PACU nurse obtained Mrs P’s blood glucose level shortly after arrival in the PACU. Mrs P’s recovery was uneventful, and on achieving phase I1 recoveIy criteria, the PACU nurse transferred Mrs P to the postoperative surgical nursing care unit. The surgeon assessed Mrs P the next morning and removed the drains. On postoperative day two, Mrs P was tolerating sitting up in bed, and her pain was well controlled with oral analgesics so the anesthesia care provider removed the epidural catheter and discontinued the patient-controlled analgesia pump. The unit nurse removed the Foley catheter and initiated oral anticoagulant medications. Staff members from the PT and OT departments visited Mrs P and initiated therapy programs. On postoperative day three, the physical therapist instructed Mrs P on touch weight bearing and the use of walking aids, which Mrs P was instructed to continue until her return appointment with the surgeon. The RNFA and a dietitian reviewed diet, exercise, and diabetic control with Mr and Mrs P. The surgeon reviewed postoperative and discharge plans with Mrs P and her

family members. Mrs P was discharged from the hospital on postoperative day five. Eight days after discharge from the hospital, Mrs P developed a 1 cm long by 0.5 cm deep dehiscence along the lower aspect of her surgical wound. Mrs P notified her surgeon by telephone. The surgeon, because of the family’s distance from the medical center, worked in collaboration with Mrs P’s local family physician to provide treatment. Mrs P was placed on oral antibiotics and instructed to perform sterile, dry dressing changes three times per day or as needed to contain drainage. Mrs P was seen once per week by her local physician for evaluation of the wound. Mrs P returned seven weeks after surgery for a follow-up appointment with her surgeon. The open portion of her wound had granulated successfully. Mrs P remained afebrile and without tenderness or discharge of fluid from the wound. Pelvic x-rays showed callous formation at the osteotomy sites. She continued with dressing changes twice per day for an additional week and then once per day for another 10 days. The wound was healed completely approximately 12 to 13 weeks postoperatively. Mrs P progressed to weight bearing as tolerated. She returned to her employment on a part-time basis after the seven-week appointment. She used a cane for two weeks after the appointment. Mrs P was progressing well at her sixth-month appointment, with full recovery at her one-year follow-up appointment with the surgeon. A Craig A. Gillett, RN, BSiV, BS, is the educatorfor orthopedic and plastic surgery at Rochester Methodist Hospital, Department of Surgical Services, Mayo Clinic, Rochestel: Minn. The author wishes to thank Robert 7: Trousdale, MD; Michael A. Nigbur, PA-C, BS; and Dale Clark. W ,BSN, for their assistance with writing this article.

NOTES 1. Y Shelton, E Mortimer, “Orthopaedic problems in the pediatic patient,” in Orthopaedics in Primary Care, third ed, G G Steinberg, C M Adkins, D T Baran,

The Adult Hip, ed J J Callaghan, A G Rosenberg, H E Rubash (Philadelphia: Lippincott-Raven, 1998) 409-413. 3. S J Ventura et al, “Report of final natality statistics 1996,”

eds (Philadelphia: Lippincott, Williams, and Wilkins, 1999) 381411. 2. Ibid; S L Weinstein, “The sequelae of pediatric hip disease,” in

Monthly Ktal Statistics Report, N 11 suppl46 (Atlanta: US Department of

Health and Human Services, June 30, 1998). 4. Weinstein, “The sequelae of 749 AORN JOURNAL

pediatric hip disease,” 409-413; J Crockarell, Jr, et al, “Early experience and results with the periacetabular osteotomy: The Mayo Clinic experience,” Clinical Orthopaedics and Related Research 363 (June 1999)45-53; R T Trousdale et al, “Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips,” The Journal of Bone and Joint

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S u t p V 77 (January 1995) 73-85: R T Trousdale, R Ganz, “Periacetabular osteotomy,” in The Adult Hip, ed J J Callaghan, A G Rosenberg, H E Rubash (Philadelphia: LippincottRaven. 1998) 789-802; S J Trumble, K A Mayo, J W Mast, “The periacetabular osteotomy: Minimum two year follow up in more than 100 hips,” Clinical Orthopaedics and Related Research 363 (June 1999) 54-63. 5. Trousdale, Ganz, “Penacetabular osteotomy,” 789-802; J H Beaty, “Congenital and developmental anomalies of hip and pelvis,” in Campbell b Operative Orthopaedics, vol I, ninth ed, S T Canale, ed (St Louis: Mosby, 1998) 1021-1052. 6. Trousdale et al, “Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips,” 7385; Trousdale, Ganz, “Periacetabular osteotomy,” 789-802; Trumble, Mayo, Mast, “The periacetabular osteotomy: Minimum two year follow up in more than 100 hips,” 5463; J W McClellan 111, K L Garvin, “Adolescent and young adult hip dysplasia: The role of Bemese periacetabular osteotomy,” Nebraska Medical Journal80 (August 1995) 27 1-276. 7. Shelton, Mortimer, “Orthopaedic problems in the pediatric patient,” third ed, 38 1-41 1; Weinstein, “The sequelae of pediatric hip disease,” 409-413; Beaty, “Congenital and developmental anomalies of hip and pelvis,” ninth ed, 1021-1052; H J ter Veer, L Ombregt, “Hip disorders in children,” in A System of Orthopaedic Medicine, ed L Ombregt (Philadelphia: WB Saunders Co Ltd, 1995) 759-762. 8. Trousdale et al, “Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips,” 7385; Trousdale, Ganz, “Periacetabular osteotoniy,” 789-802; McClellan, Garvin, “Adolescent and young adult hip dysplasia: The role of Bernese periacetabular osteotomy,” 27 1-276.

9. Trousdale, Ganz, Periacetabular osteotomy,” 789802; McClellan, Garvin, “Adolescent and young adult hip dysplasia: The role of Bemese periacetabular osteotomy,” 27 1-276. 10. Trousdale, Ganz, “Periacetabular osteotomy,” 789-802. 1 1. Ibid; McClellan, Garvin, “Adolescent and young adult hip dysplasia: The role of Bemese penacetabular osteotomy,” 271-276; R T Trousdale, J P Beckenbaugh, “Nonarthroplastic treatment of hip dysplasia in adults,” Hospital Physiciaii Orthopaedic Sutgeiy Board Review Manual. Vol6. Part 1 (2000) 2- 12. 12. Trousdale et al, “Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips,” 7385; McClellan, Garvin, “Adolescent and young adult hip dysplasia: The role of Bemese periacetabular osteotomy,” 271 -276. 13. Beaty, “Congenital and developmental anomalies of hip and pelvis,” ninth ed, 1021-1052. 14. Crockarell et al, “Early experience and results with the periacetabular osteotomy: The Mayo Clinic experience,” 45-53; Trousdale, Ganz, “Periacetabular osteotomy,” 789802; R Ganz et al, “A new periacetabular osteotomy for the treatment of hip dysplasia technique and preliminary results.” Clinical Orthopaedics and Relafed Research 232 (July 1988) 26-36; H Shindo et al, “Rotational acetabular osteotomy for severe dysplasia of the hip with a false acetabulum,” The Journal of Bone and Joinf Surgery 78 (November 1996) 871-877. 15. Crockarell et al, “Early experience and results with the periacetabular osteotomy: The Mayo Clinic experience,” 45-53; Trousdale et al, “Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips,” 7385; Shindo et al, “Rotational acetabular osteotomy for severe dysplasia of the hip with a false acetabulum,” 871-877. “

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16. Crockarell et al, “Early experience and results with the periacetabular osteotomy: The Mayo Clinic experience,” 45-53; Trousdale et al, “Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips,” 7385; Trousdale, Ganz, “Penacetabular osteotomy,” 789-802; Ganz et al, “A new periacetabular osteotomy for the treatment of hip dysplasia technique and preliminary results,” 26-36. 17. Trousdale et al, “Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips,” 73-85; Trousdale, Ganz, “Periacetabular osteotomy,” 789-802; Trumble, Mayo, Mast, “The periacetabular osteotomy: Minimum two year follow up in more than 100 hips,” 54-63; McClellan, Garvin, “Adolescent and young adult hip dysplasia: The role of Bemese periacetabular osteotomy,” 27 1-276; Ganz et al, “A new periacetabular osteotomy for the treatment of hip dysplasia technique and preliminary results,” 26-36; 0 Hersche, M Casillas, R Ganz, “Indications for intertrochanteric osteotomy after periacetabular osteotomy for adult hip dysplasia,” Clinical Orthopaedics and Related Research 347 (February 1998) 1926. 18. Crockarell et al, “Early experience and results with the periacetabular osteotomy: The Mayo Clinic experience,” 45-53; Trousdale et al, “Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips,” 7385; Trousdale, Ganz, “Penacetabular osteotomy.” 789-802; McClellan, Garvin, “Adolescent and young adult hip dysplasia: The role of Bemese periacetabular osteotomy,” 27 1-276; Ganz et al, “A new periacetabular osteotomy for the treatment of hip dysplasia technique and preliminary results,” 26-36. 19. Trousdale, Ganz, “Penacetabular osteotomy,” 789-802. 20. S Beyea, ed, Perioperative Nursing Data Set (Denver: AORN, Inc, 2002, in press).

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21. Crockarell et al, “Early experience and results with the periacetab-

ular osteotomy: The Mayo Clinic experience,” 45-53; Trousdale et al, “Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips,” 7385; Trousdale, Ganz, “Periacetabular osteotomy.” 789-802; Trumble, Mayo. Mast, “The periacetabular osteotomy: Minimum two year follow up in more than 100 hips,” 5463; McClellan, Garvin, “Adolescent and young adult hip dysplasia: The role of Bemese periacetabular osteotomy.” 271-276; Ganz et al, “A new periacetabular osteotomy for the

treatment of hip dysplasia technique and preliminary results,” 26-36. 22. Trousdale et al, “Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips,” 73-85; Trousdale, Ganz, “Periacetabular osteotomy,” 789-802; Ganz et al, “A new periacetabular osteotomy for the treatment of hip dysplasia technique and preliminary results,” 26-36; J G Hussell, J A Rodriguez, R Ganz. “Technical complications of the Bemese periacetabular osteotomy,” Clinical Orthopaedics and Related Research 363 (June 1999) 8 1-92. 23. Orthopedic Specialty Patient

Education Committee, Periacetabular Osteotomy (PAO) Orthopedic

Surgery (Rochester, Minn: Mayo Clinic Press, 1999). RESOURCES “Your orthopedic connection,” American Academy of Orthopedic Surgeons, http://orthoinfo.aaos.org (accessed 22 Jan 2002). Matta, J M. “Periacetabular osteotomy,” Hip and Pelvis.Com, http://www.hipandpelvis.com/patient -education/index.html (accessed 22 Jan 2002).

Win Prizes By Taking AORN Journal Home Studies Each time AORN members complete and pass an AORN Journal Home Study now through June 1, 2002, they will be entered in a drawing for one of the following prizes. Complimentary 2003 Congress registration A complimentary copy of the 2002 AORN Standards, Recommended Practices, and Guidelines with the accompanying study guide

Free one-year AORN membership renewal 10 complimentary contact hours to use for AORN Journal Home Studies Begin taking AORN Journal Home Studies now for the opportunity to win. You must be a member of AORN on the day your examination is received to qualify for the drawing. Completed Home Studies must be received by June 1,2002, to be entered into the drawing.

Number of Uninsured Up in 2001 Due to Unemployment The large number ofjob layoffs in 2001 added more than two million people to the ranks of the uninsured, according to a Feb 12,2002, news release from Families USA. In 2000, 39 million Americans were uninsured, a number that exceeds the total population of 22 states plus the District of Columbia. In 2001, more than 2.2 million Americans lost health insurance coverage due to increased unemployment, causing the number of uninsured to exceed the population of 23 states plus the District of Columbia. This represents the largest increase in the number of uninsured Americans in any one year since 1992. Approximately half of the increase due to layoffs occurred between September and December 200 1, indicating the impact of the Sept 11, 200 1, attack on the World Trade Center. Other causes of

health insurance loss, such as increased health care costs or cutbacks in state Medicaid programs, are not reflected in these numbers. Thus, the actual number of uninsured Americans likely is higher. Families USA and other health care and business organizations have formed a coalition to seek solutions to the problems of the uninsured. The “Covering the Uninsured” campaign aims to make expanded health coverage a top national priority to prevent millions of people from deferring needed health care. 2 Million Americans Lost Their Health Insurance in 2001 : Largest One-year Increase in Nearly a Decade (news release, Washington, DC: Families USA, Feb 12, 2002) h i t p : / W .familiesusa.org/media/press/2002/insurance -loss.htm (accessed 26 Feb 2002).

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