RU2802423C1 - Method for performing exposure during primary total knee arthroplasty - Google Patents

Abstract

FIELD: medicine; traumatology; orthopaedics.

SUBSTANCE: invention can be used to perform exposure during primary total knee arthroplasty. A skin incision is performed above the patella to the tuberosity of the tibia. The distal part of the vastus medialis muscle is isolated and arthrotomy is performed. Arthrotomy is performed from the border of the proximal and middle thirds of the medial edge of the patella, 5 mm inwards, along the inner edge of the patella, along the tendon of the patella to the tuberosity of the tibia. From the beginning of arthrotomy, the tissue of the tendon of the broad medial muscle is dissected with the transition to its muscular part proximal from its distal edge and continues in the direction of the muscle fibres proximally and posteriorly so that the distance from the distal part of the muscular part of the internal head of the quadriceps is no more than 1 cm.

EFFECT: method reduces the risk of damage to the extensor apparatus of the knee joint and neurovascular structures, creates a better overview of the surgical field and conditions for performing lateral release due to the peculiarities of dissection of the tendon of the medial vastus muscle.

1 cl, 2 dwg, 1 ex

Description

The present invention relates to medicine, namely to traumatology and orthopedics, and can be applied to total knee replacement.

The use of minimally invasive approaches accounts for 3.9% of all cases of total knee arthroplasty [Swedish Hip Arthroplasty Register, 2017]. The choice of approach may influence rehabilitation after total knee arthroplasty. The requirements for minimally traumatic approaches are determined by the peculiarities of the patient’s anatomy [Alabut A.V. et al., 2013]. Knee joint function in short-term (after 1.5-3 months) and long-term follow-up (more than 2 years) was significantly better in patients who used a minimally invasive approach for knee replacement. A relationship was found between the severity of postoperative pain syndrome and long-term results of ECC [Alcelik I. et al., 2012; Kazarian G.S. et al., 2018]. The use of low-traumatic approaches when performing knee replacement promotes early rehabilitation and increases patient satisfaction [Berstock J.R. et al., 2018; Wei B. et al., 2021]. It has been shown that maintaining muscle tone contributes to better results in knee replacement [Shimarova O.V., 2019]. Minimally invasive approach reduces the risk of revision surgery by 20% compared to the most commonly used standard technique [Blom A.W. et al., 2019]. Minimally invasive approaches are an effective alternative to the standard technique [Migliorini F. et al., 2021; Zhang L. et al., 2021].

Minimally traumatic subvastus and midvastus approaches are known.

Subvastus access (Hofmann AA. et al., 1991), includes making a skin incision, exposing the distal part of the m. vastus medialis, patella, medial patellar retinaculum, patellar ligament. When using this method, an arthrotomy is performed from the upper-middle third of the patella in the area of the tendon attachment of m. vastus medialis, further along the lower edge of m. vastus medialis posteriorly and distally along the inner edge of the patella and its tendon to the middle of the tibial tuberosity. When performing this method, it is always necessary to leave a narrow strip of tendon tissue on the lower edge of the vastus internus muscle to provide adequate strength when suturing the wound.

Contraindications for its choice as an access for knee replacement are: flexion in the knee joint less than 120 degrees, frontal deformation of the knee joint more than 15 degrees, hip circumference more than 55 centimeters, distal attachment of m. vastus medialis obliquus, occupying >60% of the length of the patella, as well as a long “learning curve”. Thus, the method has limitations.

Midvastus access is known (Cooper RE Jr. et al., 1999). When using this method, a skin incision is made to expose the distal part of m. vastus medialis, patella, medial patellar retinaculum, patellar ligament. Arthrotomy is performed from the superior internal angle of the patella, then medially along the patellar ligament proper to the tibial tuberosity. M. vastus medialis is cut along the muscle fibers at an angle of 45-50 degrees, 4.5-6 cm.

The main disadvantage of this approach is the high risk of neurovascular damage, namely a. genicular descending of the main arterial branch supplying the superolateral segment of the patella and the terminal branch of the femoral nerve (ramus infrapatellaris n. saphenus), which provides distal sensitivity to the vastus femoris muscle; limitation of visualization of the outer plate of the tibia with its excessive external rotation; absence.

This access was chosen as a prototype.

The objective of the present invention is to create an improved access for knee arthroplasty, devoid of the disadvantages of the prototype.

The technical result is reducing the risk of damage to the extensor apparatus of the knee joint and neurovascular structures, creating a better overview of the surgical field, and providing conditions for performing lateral release.

The technical result is achieved by performing an arthrotomy from the border of the proximal and middle thirds of the medial edge of the patella along the inner edge of the patella, along the patellar tendon to the tibial tuberosity; from the beginning of the arthrotomy, the tissue of the tendon of the vastus medialis is dissected with a transition to its muscular part, proximal to its distal edge and continued in the direction of the muscle fibers proximally and posteriorly so that the distance from the distal part of the muscular part of the inner head of the quadriceps is no more than 1 cm.

The essence of the proposed access is illustrated by figures, where in FIG. 1 - access diagram (front view), Fig. 2 - access diagram (view from the inside).

The minimally traumatic epivastus approach for primary total knee replacement is performed as follows. A skin incision is made above the patella and continues to the tibial tuberosity, the distal part of the vastus medialis muscle is isolated. Arthrotomy is performed from the border of the proximal and middle thirds of the medial edge of the patella (1) along the inner edge of the patella, 5 mm inward, and the patellar tendon to the tibial tuberosity (2). From the beginning of the arthrotomy (1), the tissue of the tendon of the vastus medialis muscle is dissected with a transition to its muscular part, continued in the direction of the muscle fibers proximally and posteriorly so that the distance from the distal part of the muscular part of the inner head of the quadriceps is no more than 1 cm (3) ( Fig. 1, Fig. 2).

Minimally invasive approach for primary total knee replacement eliminates the risk of damage to a. genicular descending, which supplies the extensor apparatus of the patella, the risk of damage to the terminal branch of the femoral nerve (ramus infrapatellaris n. saphenus), which provides innervation to the distal part of the vastus medialis muscle due to the fact that the arthrotomy begins from the border of the proximal and middle thirds of the medial edge of the patella, that is more distal than in the prototype, but does not impose restrictions on the use of subvastus, dissection of the tendon tissue of the vastus medialis muscle with a transition to its muscular part from the beginning of the arthrotomy, proximal from its distal edge and continuation in the direction of the muscle fibers proximally and posteriorly so that the distance from the distal part of the muscular part of the inner head of the quadriceps was no more than 1 cm.

An example of using the method

Patient N, 62 years old, was admitted with a diagnosis of “Right-sided post-traumatic gonarthrosis, stage 3.” Complaints upon admission: pain, clicking, limitation of movements, deformation of the right knee joint, impaired support and walking. I have been experiencing pain in the knee joint for several years. Notes repeated injuries to the knee joint. He walks with the help of a cane for a long time and limps on his right leg. Conservative treatment without effect. On examination: varus deformity of the right knee joint; movements in the knee joint are painful, restrictions: flexion 0\0\60 degrees; there are no symptoms of instability of the external and internal collateral ligaments; "Anterior and posterior drawer" symptoms are negative. Total arthroplasty of the right knee joint was performed as planned. Progress of the operation. The surgical field was treated 3 times with an antiseptic solution. A skin incision was made 1 cm above the patella and continued to the tibial tuberosity. The distal part of the vastus medialis muscle is highlighted. The arthrotomy began from the border of the proximal and middle third of the medial edge of the patella, then the opening continued along the inner edge of the patella, 5 mm inward, and the patellar tendon to the tibial tuberosity. About 20 ml of yellow synovial fluid was released. From the site of the beginning of the arthrotomy, the tissue of the tendon of the vastus medialis muscle was dissected with a transition to its muscular part, proximal to its distal edge and continued in the direction of the muscle fibers proximally and posteriorly at a distance of 5 cm so that the maximum distance from the distal edge was 1 cm. A partial excision of the Hoffa fatty body for better visualization of the lateral part of the knee joint, resection of the external and internal menisci, anterior cruciate ligament. Synovectomy and lateral release of the patella were performed. The patella was dislocated outwards, a modeling resection of the patella and peripheral deinervation were performed. The condyles of the femur and tibia are deformed with subsidence of the internal condyle, there is no cartilage on the articular surfaces, there are multiple osteochondral growths along the edges of the condyles of the femur and tibia, the latter have been removed. The femoral condyles were resected to accommodate a size E femoral component, and the tibial condyles were processed to accommodate a size 5 tibial pad. Symmetrical extensor and flexion gaps are formed. The control components of the endoprosthesis are installed, the limb axis is correct, the range of motion in the joint is sufficient after installing the tibial insert template with a height of 12 mm. The epicondyles of the femur and tibia were installed with original components on bone cement, and the biological axis of the limb was reconstructed. During the operation, thorough hemostasis was performed, and the wound was washed with an antiseptic solution. Layer-by-layer suturing of the surgical wound tightly. Aseptic dressing. The patient was transferred to the ICU until the spinal block resolved. Dosed support on the operated limb is allowed the next day. On the 4th day after surgery, the range of motion in the operated joint was 0\0\80, the pain score on the VAS scale was 1 point. The control x-ray shows the correct position of the components. At a follow-up examination after 2 months, it was noted: range of motion 0\0\110, VAS - 0.

Claims (1)

A method of performing access for primary total knee replacement, including making a skin incision above the patella to the tibial tuberosity, isolating the distal part of the vastus medialis muscle, performing an arthrotomy, characterized in that the arthrotomy is performed from the border of the proximal and middle thirds of the medial edge of the patella, indenting 5 mm medially, along the inner edge of the patella, along the patellar tendon to the tibial tuberosity; from the beginning of the arthrotomy, the tissue of the tendon of the vastus medialis is dissected, moving to its muscular part proximally from its distal edge and continues in the direction of the muscle fibers proximally and posteriorly so that the distance from the distal part of the muscular part of the inner head of the quadriceps is no more than 1 cm.