FRCS Paediatric Ortho — improved notes
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010. DDH open reduction approaches

visual-inline rebuild1 extracted figuresspeaker notes XML63 study lines3 Q&A

Individual slide images have been cropped from the rendered slide and inserted beside the matching note section. The full slide remains below only for layout/audit.

Clean FRCS notes with inline figures

Open reduction

Operative / approach image - open reduction approach diagram
Fig 1. Operative / approach image - open reduction approach diagramtop left
•Anterior vs medial

Anterior:

Absolute indications

•High and chronic dislocations, femoral head stuck to ilium (>1-1.5yo)
•Perform capsulorrphahy for very unstable hips
•Plan acetabuloplasty

Adv:

•Good exposure (easier in sizable child)
•Can do capsulorrhaphy
•Can reduce highly dislocated hip

Disadv:

•Large wound, more bleeding
•Iliac crest apophysis and hip abductor at risk
•LCFN at risk

Key steps:

•Bikini incision +/- extend proximal along iliac crest
•Protect LCFN
•Plane between sartorius and TFL
•+/- Split iliac apophysis and release glut med from outer table
•Plane between rectus and glut med
•Detach and tag straight head and reflected head of rectus
•Psoas tendon lengthening at the pelvic brim
•T capsulotomy, acetabular based
•Excision of intraarticular obstacles to reduction (ligamentum teres, pulvinar)
•+/- acetabular / femoral osteotomy
•Capsulorrhaphy

Medial (Weinstein / Ludloff / Ferguson):

•Abs c/i (~>18mo)

Adv:

•Small wound and less bleeding
•Can deal with some of the pathology (iliopsoas, transverse acetabular ligament)
•Avoid stripping of iliac apophysis and abductors
•Adductor tenotomy through same incision

Disadv:

•Risk of injury to MCFA → AVN
•Cannot perform capsulorrhaphy
•Obturator nerve injury
•Ant div supply gracilis, adductor longus, adductor brevis, lies on add brevis
•Post div supply add magnus, lies on add magnus
•(Ischial portion of add magnus supply by sciatic n)
•Not for open reduction within 6mth

How to do medial approach

•GA (usually children), supine, affected limb in abduction, flexion and ER
•Landmark: 3cm below pubic tubercle (attachment of adductor longus)
•Incision: longitudinal just below pubic tubercle and along adductor longus

Dissection plane:

•Weinstein = between NVB and pectineus (best to reach labrum as the pectineus is not in the way, surgical landmark will be the anterior obturator nerve)
•Ludloff = between pectineus and AB
•Ferguson = between AL and G, then AB and AM
•Adductor tendon release as necessary
•Palpate lessor tuberosity, release iliopsoas (care to protect MCFA)
•Capsulotomy, acetabular based
•Release ligamentum teres, pulvinar
•If go superficial to pectineus (Weinstein), can approach superior aspect of hip joint also

Structure at risk:

•Obturator nerve (anterior branch of obturator nerve between adductor longus and brevis → injury causing adductor contracture)
•Medial circumflex femoral artery (near psoas tendon, need direct vision when performing tenotomy, do capsulotomy close to acetabulum)
•External pudendal artery (superficial to pectineus)
•Femoral vessels (Weinstein)
•Innervation of medial compartment
•Adductor magnus: posterior branch of obturator nerve + tibial nerve
•Others by anterior branch of obturator nerve

Direct Q&A

Q1 What are the indications listed for DDH open reduction approaches?
•High and chronic dislocations, femoral head stuck to ilium (>1-1.5yo)
•Perform capsulorrphahy for very unstable hips
•Plan acetabuloplasty
Q2 What operative steps, indications, and risks are listed for How to do medial approach?
•GA (usually children), supine, affected limb in abduction, flexion and ER
•Landmark: 3cm below pubic tubercle (attachment of adductor longus)
•Incision: longitudinal just below pubic tubercle and along adductor longus
Q3 Which anatomical structures or danger structures are listed under Structure at risk?
•Obturator nerve (anterior branch of obturator nerve between adductor longus and brevis → injury causing adductor contracture)
•Medial circumflex femoral artery (near psoas tendon, need direct vision when performing tenotomy, do capsulotomy close to acetabulum)
•External pudendal artery (superficial to pectineus)
•Femoral vessels (Weinstein)
•Innervation of medial compartment
•Adductor magnus: posterior branch of obturator nerve + tibial nerve
•Others by anterior branch of obturator nerve

Raw speaker-note hierarchy audit

#lvlmarLindentlogicaloriginal note line
10NoneNone0Open reduction
20NoneNone0Anterior vs medial
30NoneNone0Anterior:
40NoneNone0Absolute indications
50171450-1714501High and chronic dislocations, femoral head stuck to ilium (>1-1.5yo)
60171450-1714501Perform capsulorrphahy for very unstable hips
70171450-1714501Plan acetabuloplasty
80NoneNone0Adv:
90171450-1714501Good exposure (easier in sizable child)
100171450-1714501Can do capsulorrhaphy
110171450-1714501Can reduce highly dislocated hip
120000Disadv:
130171450-1714501Large wound, more bleeding
140171450-1714501Iliac crest apophysis and hip abductor at risk
150171450-1714501LCFN at risk
160000Key steps:
170228600-2286001Bikini incision +/- extend proximal along iliac crest
180228600-2286001Protect LCFN
190228600-2286001Plane between sartorius and TFL
200228600-2286001+/- Split iliac apophysis and release glut med from outer table
210228600-2286001Plane between rectus and glut med
220228600-2286001Detach and tag straight head and reflected head of rectus
230228600-2286001Psoas tendon lengthening at the pelvic brim
240228600-2286001T capsulotomy, acetabular based
250228600-2286001Excision of intraarticular obstacles to reduction (ligamentum teres, pulvinar)
260228600-2286001+/- acetabular / femoral osteotomy
270228600-2286001Capsulorrhaphy
280000Medial (Weinstein / Ludloff / Ferguson):
290000Abs c/i (~>18mo)
300000Adv:
310171450-1714501Small wound and less bleeding
320171450-1714501Can deal with some of the pathology (iliopsoas, transverse acetabular ligament)
331171450-1714501Avoid stripping of iliac apophysis and abductors
341171450-1714501Adductor tenotomy through same incision
351001Disadv:
360171450-1714501Risk of injury to MCFA → AVN
370171450-1714501Cannot perform capsulorrhaphy
380171450-1714501Obturator nerve injury
391628650-1714502Ant div supply gracilis, adductor longus, adductor brevis, lies on add brevis
401628650-1714502Post div supply add magnus, lies on add magnus
411628650-1714502(Ischial portion of add magnus supply by sciatic n)
420NoneNone0Not for open reduction within 6mth
430NoneNone0How to do medial approach
440171450-1714501GA (usually children), supine, affected limb in abduction, flexion and ER
450171450-1714501Landmark: 3cm below pubic tubercle (attachment of adductor longus)
460171450-1714501Incision: longitudinal just below pubic tubercle and along adductor longus
470171450-1714501Dissection plane:
481628650-1714502Weinstein = between NVB and pectineus (best to reach labrum as the pectineus is not in the way, surgical landmark will be the anterior obturator nerve)
491628650-1714502Ludloff = between pectineus and AB
501628650-1714502Ferguson = between AL and G, then AB and AM
510171450-1714501Adductor tendon release as necessary
520171450-1714501Palpate lessor tuberosity, release iliopsoas (care to protect MCFA)
530171450-1714501Capsulotomy, acetabular based
540171450-1714501Release ligamentum teres, pulvinar
550171450-1714501If go superficial to pectineus (Weinstein), can approach superior aspect of hip joint also
560171450-1714501Structure at risk:
571628650-1714502Obturator nerve (anterior branch of obturator nerve between adductor longus and brevis → injury causing adductor contracture)
581628650-1714502Medial circumflex femoral artery (near psoas tendon, need direct vision when performing tenotomy, do capsulotomy close to acetabulum)
591628650-1714502External pudendal artery (superficial to pectineus)
601628650-1714502Femoral vessels (Weinstein)
610171450-1714501Innervation of medial compartment
621628650-1714502Adductor magnus: posterior branch of obturator nerve + tibial nerve
631628650-1714502Others by anterior branch of obturator nerve

Improved semantic hierarchy used for the study notes

#semantic levelsection?rewritten line
10Open reduction
21Anterior vs medial
30yesAnterior:
40yesAbsolute indications
51High and chronic dislocations, femoral head stuck to ilium (>1-1.5yo)
61Perform capsulorrphahy for very unstable hips
71Plan acetabuloplasty
80yesAdv:
91Good exposure (easier in sizable child)
101Can do capsulorrhaphy
111Can reduce highly dislocated hip
120yesDisadv:
131Large wound, more bleeding
141Iliac crest apophysis and hip abductor at risk
151LCFN at risk
160yesKey steps:
171Bikini incision +/- extend proximal along iliac crest
181Protect LCFN
191Plane between sartorius and TFL
201+/- Split iliac apophysis and release glut med from outer table
211Plane between rectus and glut med
221Detach and tag straight head and reflected head of rectus
231Psoas tendon lengthening at the pelvic brim
241T capsulotomy, acetabular based
251Excision of intraarticular obstacles to reduction (ligamentum teres, pulvinar)
261+/- acetabular / femoral osteotomy
271Capsulorrhaphy
280yesMedial (Weinstein / Ludloff / Ferguson):
291Abs c/i (~>18mo)
300yesAdv:
311Small wound and less bleeding
321Can deal with some of the pathology (iliopsoas, transverse acetabular ligament)
331Avoid stripping of iliac apophysis and abductors
341Adductor tenotomy through same incision
350yesDisadv:
361Risk of injury to MCFA → AVN
371Cannot perform capsulorrhaphy
381Obturator nerve injury
392Ant div supply gracilis, adductor longus, adductor brevis, lies on add brevis
402Post div supply add magnus, lies on add magnus
412(Ischial portion of add magnus supply by sciatic n)
421Not for open reduction within 6mth
430yesHow to do medial approach
441GA (usually children), supine, affected limb in abduction, flexion and ER
451Landmark: 3cm below pubic tubercle (attachment of adductor longus)
461Incision: longitudinal just below pubic tubercle and along adductor longus
470yesDissection plane:
482Weinstein = between NVB and pectineus (best to reach labrum as the pectineus is not in the way, surgical landmark will be the anterior obturator nerve)
492Ludloff = between pectineus and AB
502Ferguson = between AL and G, then AB and AM
511Adductor tendon release as necessary
521Palpate lessor tuberosity, release iliopsoas (care to protect MCFA)
531Capsulotomy, acetabular based
541Release ligamentum teres, pulvinar
551If go superficial to pectineus (Weinstein), can approach superior aspect of hip joint also
560yesStructure at risk:
572Obturator nerve (anterior branch of obturator nerve between adductor longus and brevis → injury causing adductor contracture)
582Medial circumflex femoral artery (near psoas tendon, need direct vision when performing tenotomy, do capsulotomy close to acetabulum)
592External pudendal artery (superficial to pectineus)
602Femoral vessels (Weinstein)
611Innervation of medial compartment
622Adductor magnus: posterior branch of obturator nerve + tibial nerve
632Others by anterior branch of obturator nerve
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