RU2502488C1 - Method of front-lateral access for hip endoprosthetics - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to traumatology and orthopedics. Patient is placed on healthy side, operated extremity is brought backwards, penetration is realised by spreading space by means of gluteus medius muscle and tensor of broad fascia, distal edge of front-lower portion of tendon of gluteus medius muscle is additionally transversally cut with half a centimeter indent from the place of it fixation to femoral bone.

EFFECT: improving hip joint functions in postoperative period, acceleration of rehabilitation period and reduction of terms of patients' hospitalisation.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used when performing hip replacement surgery to treat pathology with severe degenerative-dystrophic changes in cases of diseases of the hip joint, fractures and severe consequences of fractures of the proximal femur.

The number of hip arthroplasty operations in the world is increasing annually and reaches 1 million per year [7]. The anterolateral and posterolateral approaches to the hip joint are mainly used as the most sparing for the neurovascular formations of the proximal femur and pelvis. The search for ways to reduce the morbidity of surgical aggression, to reduce the amount of damage to the muscle and capsule-ligamentous apparatus of the hip joint has become a new, objectively necessary stage in the further development of technologies for total hip joint replacement. One of the promising solutions to this stage was minimally invasive hip replacement, the main feature of which is the use of intermuscular spaces without cutting off the muscles. This allows you to slightly reduce the time of inpatient treatment and rehabilitation period. The negative side of minimally invasive techniques is the increased technical complexity of the implementation, a decrease in the visualization of the surgical field. In some cases, this can lead to intraoperative complications [1].

An analogue of the invention is the anterolateral method (according to Mueller), performed in the patient's position on the healthy side and characterized in that the anterior portion of the tendon m. gluteus medius intersects for 3 cm at the point of attachment to the greater trochanter of the femur so that there remains a tendon cuff for subsequent muscle recovery. Further, the incision continues from 3 to 4 cm along the muscle fibers m. gluteus medius in the proximal direction to the upper part of the lip of the acetabulum [6] (figure 1). This opens access to the hip joint with the saved area of attachment of the posterior part of the middle gluteal muscle. During the operation, the operated limb moves anterior to the patient for the next surgical stages. Due to the anatomical features, often there is tension in the saved front sections of the middle gluteal muscle and their separation from the femur [6]. This makes it difficult to restore damaged areas and negatively affects the further function of the joint [1].

The prototype of the invention was the Rottinger method [2]. This method allows for hip joint arthroplasty from the intermuscular gap formed by m. tensor fasciae latae and m. gluteus medius without dissection (figure 2). In this case, the patient is laid on a healthy side, the operated lower limb is taken back from the patient. However, the preservation of the attachment sites of the entire muscle mass significantly impedes visualization and reduces the area of surgical action, which does not always allow successful surgical intervention in difficult clinical situations.

The technical result of the invention consists in improving the function of the hip joint, in accelerating the rehabilitation period and in reducing the time of hospitalization of patients; the implementation of the proposed access with cutting off the distal edge of the anteroposterior portion of the tendon of the middle gluteal muscle provides an optimal angle of inclination of the axis of the surgical action, maintains normal functional results and significantly improves the overview of the surgical area; moving the operated lower limb posterior to the patient allows you to relax the main saved massif of the middle gluteal muscle and thus minimize its trauma during further surgical operations.

The result of the invention is achieved by cross-cutting the distal edge of the antero-lower portion of the tendon of the middle gluteal muscle for 1 to 2 cm (depending on the severity of development of the pelvic girdle muscle mass). The tendon intersects, retreating 0.5 cm from its attachment to the greater trochanter.

The figures depict:

Figure 1. The Mueller method, where 1 is the intersection of the anterior portion of the tendon m. gluteus medius for 3 cm at the point of attachment to the greater trochanter of the femur; 2 - dissection from 3 to 4 cm along the muscle fibers m. gluteus medius in the proximal direction to the upper part of the lip of the acetabulum.

Figure 2. The Rottinger method, where 3 is the "intermuscular" access to the capsule of the hip joint between m. tensor fasciae latae and m. gluteus medius over 8 cm (indicated by a dashed line).

Figure 3. The position of the patient on the orthopedic table, dismantling the rear half of the foot of the orthopedic table.

Figure 4. The method of antero-lateral access, where 3 - "intermuscular" access to the capsule of the hip joint between m. tensor fasciae latae and m. gluteus medius over 8 cm (indicated by a dashed line); 4 - dissection of the anterior-distal portion of the tendon m. gluteus medius from 1 to 2 cm, departing 0.5 cm from the point of attachment to the femur (indicated by a solid line).

Figure 5. The position of the lower limb posterior to the patient.

Figure 6. View of the surgical wound at the stage of access to the hip joint, where 5 - large trochanter, 6 - m. gluteus medius, 7 -m. tensor fasciae latae.

Figure 7. Radiography of the hip joint before surgery.

Figure 8. X-ray of the hip joint after total arthroplasty, performed by a modified antero-lateral method.

The method is as follows: the patient is placed on an orthopedic table in a position on the healthy side, while his pelvis is tightly fixed with stops strictly perpendicular to the horizontal surface of the table. Dismantled the rear half of the foot of the table for the subsequent stages of the operation (figure 3). The surgical field is delimited by sterile linen so that the operated limb remains mobile. A sterile pocket is formed behind the patient to accommodate the lower limb after the stage of hip dislocation. A skin incision is made 8-10 cm long (depending on the severity of subcutaneous fat) from a point located in the projection of the femur 2 cm distal to the apex of the greater trochanter, in the oblique-transverse direction anteriorly and upward along the axis of the neck to the anterior superior iliac spine bones. After dissection of the fiber and visualization of the wide fascia, the latter exfoliates in the direction of the skin incision. The assistant takes the lower limb 20 degrees to relax the middle and small gluteal muscles. The intermuscular gap of Watson-Jones is determined, along which m is pushed apart. tensor fasciae latae and m.gluteus medius for 8 cm. Next, in order to better visualize the acetabulum and the proximal femur (the concept of the "mobile window"), transversely intersect from 1 to 2 cm (depending on the severity of the development of the pelvic muscle mass the patient’s belt) of the distal edge of the antero-lower portion of the tendon of the middle gluteal muscle, 0.5 cm away from the point of attachment to the femur (Fig. 4). Half a centimeter of the tendon of the middle gluteal muscle at the site of attachment to the femur is saved for its subsequent restoration at the stage of suturing the surgical wound. The intersection of 1 to 2 cm of the tendon of the middle gluteal muscle provides relaxation of its main part at the stage of dislocation of the thigh and during the stage of processing the acetabulum. This technique prevents the separation of the fibers of the middle gluteal muscle from the greater trochanter. Retractors are installed: one above the neck of the femur to the joint capsule, deflecting the middle and small gluteus maximus muscles, and the second underneath, thereby ensuring m. tensor fasciae latae. After this, the front-lower surface of the capsule of the hip joint becomes accessible. The latter is dissected or excised, depending on the preference of the surgeon. Dislocation of the femur is performed by external rotation, adduction, moderate traction and extension of the femur with the movement of the lower limb posterior to the patient (figure 5). To perform this procedure, it is necessary to use an orthopedic table with a split leg part, the back of which is dismantled from the patient when laying the patient (figure 3). The neck and head of the femur are excreted into the wound, which is resected by an oscillating saw according to preoperative planning. The femoral head is removed, the lower limb is transferred to a neutral position on the table, after which the acetabulum is processed and the acetabular component is introduced. To process the bone marrow canal, the lower limb is again transferred to the position posterior to the patient. At the same time, the anterior array of the middle gluteal muscle relaxes, which allows retractors to be installed without additional trauma and to bring the proximal femur into the wound. The bone marrow canal is sequentially treated with rasps and the femoral component is installed. With the access in question, it is preferable to use indirect anatomical femoral components, for example, Muller type, which allow the inner surface of the greater trochanter to remain intact. After reduction of the endoprosthesis head, the joint retains almost “natural” anatomy and stability by maintaining fixation of the main part of the middle gluteus and other abducting muscles.

In the proposed method, a standard set of tools for performing an endoprosthetics operation is required. The use of minimally invasive instruments reduces the time of surgery.

Figure 6 presents a photograph during surgery at the stage of access to the hip joint. The surgical access zone and the intact main part of the gluteus maximus muscle are visible.

This technique, due to minor trauma to the soft tissues, allows for early painless activation of patients in the postoperative period, which significantly improves the quality of life of patients and allows for an early return to the premorbid level of physical and social activity.

Clinical example.

In the period from September 2010 to December 2011, we performed 30 operations using the proposed method. A biomechanical and clinical evaluation of the results of endoprosthetics was carried out. All patients noted a lower intensity of pain after surgery (on average, YOUR score was 3.6 points versus 5.2 after using standard surgical approaches) and could walk without crutches (with a cane) 10 days after surgery. During this period, the functional index on the Harris scale averaged 80.3 points, in contrast to 29.7 in the standard access group [3, 4, 5]. Thus, the analysis of the immediate results of endoprosthetics confirms the improvement of the function of the hip joint and earlier recovery of patients after applying the proposed method.

Patient S., 58 years old, with a diagnosis of right-sided dysplastic coxarthrosis of the 3rd st. Underwent surgical treatment using the proposed access in the clinic. R.R. Harmful (Fig.7). On October 12, 2010, the operation was performed:

total hybrid endoprosthetics of the right hip joint. The operation time was 95 minutes, and blood loss was 600 ml. In the early postoperative period, the patient was allowed to walk with crutches with a full load on the operated limb for 5 days. From 5 to 10 days it is allowed to use 1 crutch, and from 11 postoperative days - with a cane. At discharge, the full load on the operated limb is allowed. On the 10th day after the operation, the pain level on the YOUR scale was 4 points, and the Harris index was 85 points. The wound healed by primary intention, and an X-ray evaluation of the results of the endoprosthetics was considered good (Fig. 8).

Information sources

1. Baker A.S. Abductor function after total hip replacement. An electromyographic and clinical review./ Baker A.S., Bitounis V.C. // J. Bone Joint Surg. - 1989 - N71 (1) - P. 47-50.

2. Berlin K.C., Rottinger H. Anterolateral mini-incision hip replacement surgery: a modified Watson-Jones approach.// Clin Orthop Relat Res 2004; 429: 248-55.

3. Harris, W.H. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation / W.H. Harris // J. Bone Joint Surg. - 1969. - Vol. 51-A, N4. - P.737-755.

4. Huskisson E.C. Measurement of pain. Lancet 1974; 2: 1127-31.

5. Miller MD, Ferris DG. Measurement of subjective phenomena in primary care research: the visual analogue scale. Fam. Pract. ResJ. 1993; 13: 15-24.

6. Muller M.E. Total hip prosthesis.// Clin Orthop 1970; 72: 54-68.

7. Soderman P. On the validity of the results from the Swedish National Total Hip Arthroplasty register.//Acta Orthop Scand Suppl. - 2000 Dec; - 71 (296): 1-33.

Claims (1)

An antero-lateral approach for hip arthroplasty, including the patient’s position on the healthy table on the healthy side, posterior movement of the operated lower limb and penetration by spreading the gap between the gluteus maximus muscle and the wide fascia tensor, characterized in that they further cross laterally the distal edge of the anterior- the lower portion of the tendon of the middle gluteus muscle, retreating half a centimeter from where it was attached to the femur.

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