RU2395239C1 - Method of hip joint prosthetics - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to medicine, namely to surgery and can be used in oncology in case of hip joint prosthetics caused by primary and metastatic tumours of femoral bone proximal part. Replacement of soft tissue deficiency is carried out by mobilisation of vascularised muscular flap, which represents Sartorius, cut in place of attachment to knee joint. It is brought to lateral surface of upper third of hip and fixed with sutures to remaining part of muscle straining broad fascia of the thigh (m.tensor fasciae latae), external vastus muscle of thigh (m.vastus lateralis), biceps muscle of thigh (m.biceps femoris), gluteus maximus muscle (m.glutaeus maximus), quadrate muscle of thigh (m.quadratus femoris). ^ EFFECT: method allows to extend indications for endoprosthetics, reduce possibility of infectious complications development, reduce volume of donor zone trauma. ^ 1 ex

Description

The invention relates to medicine, namely to surgery, and can be used in oncology for hip joint arthroplasty for primary and metastatic tumors of the proximal femur.

Currently, in the field of hip arthroplasty, regarding primary and metastatic tumors of the proximal femur, there are still many unsolved problems. One of them is the impossibility of performing arthroplasty in case of deficiency of the soft tissues surrounding the joint. In particular, it is not possible to form a muscle bed to cover the endoprosthesis in the case of a pronounced soft tissue component of the tumor, or the anatomical features of the endoprosthetics area (patients with asthenic type of addition, cachexia). The contact of the endoprosthesis with the skin often leads to the formation of pressure sores, followed by suppuration of the postoperative wound, followed by septic instability of the endoprosthesis.

Closest to the claimed invention, in terms of features, is a method of hip joint replacement described in the “Atlas of Oncological Operations” edited by V.I. Chissov, A.Kh. Trakhtenberg, A.I. Paches, M., “GEOTAR-MEDIA ", 2008. Adopted as a prototype. In accordance with the known method, after the installation of the endoprosthesis, the remains of the resected muscles are directly sutured to each other. The disadvantages of the prototype method are:

- high probability of necrosis of the remnants of stitched muscles,

- high probability of seam divergence,

- decrease in functional results.

The claimed invention is aimed at solving the problem of improving the technique of hip joint replacement with a deficiency of soft tissues surrounding the joint.

Using in clinical practice the proposed method allows to achieve several technical (therapeutic) results:

- expand indications for arthroplasty,

- reduce the likelihood of developing infectious complications,

- reduce the amount of operating injury (donor area).

A feature of the proposed method for hip arthroplasty is that after the implant is installed, soft tissue deficiency is replaced by mobilizing a vascularized muscle flap, which is a tailor muscle, crossed at the point of attachment to the knee joint, transposing it to the lateral surface of the upper third of the thigh and fixing the flap with nodules stitches to the remnants of the muscle straining the wide fascia of the thigh (m. tensor fasciae latae), the external broad muscle of the thigh (m. vastus lateralis), two-headed oh thigh muscles (m. biceps femoris), the gluteus maximus muscle (m. glutaeus maximus), square thigh muscle (m. quadratus femoris).

The invention consists in the following.

The inventors have developed a technique for the reconstructive-plastic stage of endoprosthetics, which allows you to adequately cover the installed endoprosthesis using a vascularized tailor muscle flap. The advantage of using this muscle flap to cover the endoprosthesis is the superficial location of the muscle, which ensures the availability and ease of graft collection during surgery. The location of the vessels supplying the graft enables greater surgeon maneuverability during transposition of a muscle flap.

The method is as follows.

Hip arthroplasty is performed under general anesthesia. The position of the patient on a healthy side. On the outer surface of the thigh, in the projection of the greater trochanter, a linear incision is made of the skin and subcutaneous fat, fascia. In a dull and sharp way, soft tissues are separated to the sides. The second stage is the selection of the neurovascular bundle. The third stage is the mobilization of the tumor with the underlying muscles, which are resected. The capsule of the hip joint is opened and excised along the edge of the acetabulum. After mobilization, a proximal femur is resected. Next, implantation and assembly of the endoprosthesis are performed. To form the muscle bed covering the endoprosthesis, it is necessary to replace the deficit of soft tissues. To this end, mobilization is carried out throughout and crossing at the place of attachment of the tailor muscle to the knee joint. The muscle is transposed to the lateral surface of the upper third of the thigh and fixed with nodal sutures to the remains of the muscle straining the broad fascia of the thigh (m. Tensor fasciae latae), the external broad muscle of the thigh (m. Vastus lateralis), the biceps femoris (m. Biceps femoris) , gluteus maximus muscle (m. glutaeus maximus), quadratus femoris muscle (m. quadratus femoris). Layered seams on the wound. In the wound, active drainage is left for one to two days.

Execution example.

Patient S., 65 years old, medical history TA-7722, was treated in the fifth surgical department (oncology orthopedics) with a diagnosis of cancer of the right kidney, condition after surgical treatment 03.2008. Progression of the process: metastases to the proximal left femur, pathological fracture of the proximal left femur, pain.

In March 2008, a right-sided nephrectomy was performed at the place of residence in Tambov. In June 2008, a proximal lesion of the left femur was diagnosed. In connection with the intensification of the pain syndrome and violation of the supporting function of the left lower limb, in October 2008, she turned to the Moscow Research Institute of Medicine. P.A. Herzen.

After examination and preoperative preparation of the patient, December 16, 08, surgical treatment was performed in the amount of: resection of the proximal left femur with hip replacement.

Operation progress: patient's position on the right side. On the outer surface of the thigh, in the projection of the greater trochanter, a linear incision was made in the skin and subcutaneous fat, fascia. During the audit, the presence of a pronounced soft-tissue component in the region of the 3 thigh bone and tumor infiltration of the muscles of the anterior and lateral surfaces of the thigh, the muscle straining the wide fascia of the thigh (m. Tensor fasciae latae), the external broad muscle of the thigh (m. Vastus lateralis), the biceps thigh muscles (m. biceps femoris), gluteus maximus muscle (m. glutaeus maximus), quadratus femoris muscle (m. quadratus femoris). The femoral neurovascular bundle is intimately adjacent to the surface of the tumor without signs of invasion.

With great technical difficulties, the femoral artery and vein with the intersection of the outgoing deep arteries and veins of the thigh were isolated and held on the holders.

A blunt and sharp path made access to the hip joint. Its capsule was opened and a dislocation of the head of the left femur was made.

At a distance of 160 mm from the apex of the greater trochanter, a resection of the proximal femur was performed. The drug is removed.

A modular endoprosthesis has been implanted and assembled.

The edges of the resected muscles and the wide fascia of the thigh are partially stitched together with the formation of a defect measuring 70 × 50 mm. Given the pronounced volume of resected soft tissues, a tailor muscle was mobilized throughout and crossed at the point of attachment to the knee joint to cover the endoprosthesis bed, which is then moved to the area of the installed endoprosthesis and fixed with nodal sutures with the edges of the resected muscles and wide fascia of the thigh.

The dialysis system is installed.

Layered suture of the wound. Stitches on the skin leaving drainage under the skin.

The postoperative period was uneventful. Subcutaneous drainage and dialysis system are removed on the second and third day after surgery, respectively. The wound healed by first intention, the sutures were removed on the 14th day. In the postoperative period from the third to the seventh day, a passive, from the 7th day, active development of the hip joint was performed. At discharge, the range of motion in the hip joint: flexion - 90 °, extension - 180 °.

Control examination after three months - range of motion in the hip joint: flexion - 100 °, extension - 180 °. The function of the knee, ankle joints in full.

On the lateral surface of the hip joint, the skin is of normal color, physiological tension of the skin, no trophic disorders. The soft tissue layer between the endoprosthesis and the skin is palpated.

The inventive method has significant advantages and meets the criteria of patentability.

Claims (1)

A method for hip joint replacement, characterized in that after the installation of the endoprosthesis, soft tissue deficiency is replaced by mobilizing a vascularized muscle flap, which is a tailor muscle, crossed at the site of attachment to the knee joint, transposing it to the lateral surface of the upper third of the thigh and fixing the flap with interrupted sutures to the remnants of the muscle straining the wide fascia of the thigh (m.tensor fasciae latae), the external broad muscle of the thigh (m.vastus lateralis), the biceps femoris (m.biceps femoris), b the gluteus maximus muscle (m. glutaeus maximus), the quadratus femoris muscle (m. squadratus femoris).