RU2840700C1 - Method for access when performing total hip replacement with preserving integrity of piriform muscle - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology and orthopaedics, and can be used for making an approach in total hip replacement with preserving the integrity of the piriform muscle. Operated extremity is bent in a knee, pulling it to a hip so that the corner between a projection of the average line of a hip and an axial plane of body made 10-15 degrees. Position of the greater trochanter is determined, from the projection of the centre of which 4 cm is indented in the proximal direction, 2 cm in the dorsal direction, skin and subcutaneous fat are incised throughout 14 cm in parallel to a projection of a median line of thigh. Fascia lata is opened, a projection of the sciatic nerve is imaged; surgical Hohmann retractor is used to mobilize a tendon of a piriform muscle throughout 2.5-3 cm from a piriform fossa. Piriform muscle is taken aside ventrally; joint capsule is opened by T-incision. Tension of the piriform muscle is reduced by bending the extremity in the hip joint to angle of 70°.

EFFECT: method provides maximum preservation of the integrity of muscular tissues surrounding the hip joint and providing its functioning, elimination of dislocations in immediate postoperative period due to mobilization of piriform muscle and limited T-shaped incision of hip joint capsule, and sparing flexion in the hip joint, which reduces the tension of the piriform muscle, which allows leaving all its fibres intact throughout any stage of the operation.

1 cl, 10 dwg, 1 ex

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used to increase the preservation of muscle tissue and improve the functional result of total hip arthroplasty.

Hip replacement surgery is a popular procedure affecting a large proportion of orthopedic patients worldwide. This is due to the aging of the population, the prevalence of obesity, which places excessive strain on the large joints of the legs, a sedentary lifestyle associated with muscle fragility and increased fragility of bone tissue, and a number of other factors.

Today, the classical types of surgical approaches to the hip joint during its replacement include direct anterior, direct posterior, lateral and anterolateral. In the scientific and medical literature, information appears on newly proposed modified access options, including minimally invasive ones, aimed at reducing the trauma of surgical treatment and / or improving the functional outcome in the postoperative period [Shubnyakov I.I. et al. The main trends in hip arthroplasty based on the data of the arthroplasty registry of the R.P. Vreden National Medical Research Center of Traumatology and Orthopedics from 2007 to 2020 / Traumatology and Orthopedics of Russia. 2021. - Vol. 27, No. 3. - P. 119-142].

Among the disadvantages and complications developing in the postoperative period of hip arthroplasty, suppuration, development of osteomyelitis, dislocation of the head of the prosthesis, more often registered when choosing a posterolateral approach, inadequate rotational installation of the prosthesis, fracture of the proximal femur are noted. A particularly highlighted problem is the increase in postoperative mortality in patients of all age groups [Allakhverdiev A.S. Optimization of transosseous osteosynthesis technology in the treatment of patients with femoral neck fractures: diss... candidate of medical sciences, Kurgan, 2016].

The above indicates the demand for searching and developing new schemes for performing total hip arthroplasty, which will allow us to minimize or completely eliminate the currently known shortcomings of surgical treatment of degenerative changes in the hip joints.

A modified method of posterolateral access to the hip joint for performing endoprosthetics for intra-articular fractures of the proximal femur is known, which allows for a reduction in the incidence of dislocations in the postoperative period, improvement of hip joint function, and preservation of the piriformis and other thigh muscles [Patent RU No. 2397721].

The authors proposed making a skin incision in an oblique transverse direction from a point located in the projection of the femur 2 cm below the apex of the greater trochanter posteriorly and upwards along the axis of the neck. Next, the broad fascia is longitudinally dissected posteriorly from the femur, the square and external obturator muscles and the posteroinferior surface of the joint capsule are dissected from the area of attachment of the transverse ligament to the bone upwards to the base of the neck.

The disadvantages of this method include difficult access to the acetabulum, a high degree of injury to muscles and tendons. When accessing and treating the femur, there is a high probability of damaging the sciatic nerve, which is located near the quadratus femoris muscle dissected by the authors.

A method of total hip arthroplasty is known [Patent RU No. 2407475], aimed at preventing periprosthetic hematoma, promoting early rehabilitation and improving the patient's quality of life. When performing the method, an anterolateral approach to the joint is performed with mobilization of the gluteus medius muscle and the muscle tensor of the broad fascia of the thigh. The capsule is dissected crosswise with the formation of the upper-inner, lower-inner, lower-outer, and upper-outer capsular flaps. The upper-outer flap is sutured with the upper-inner flap and the resulting suture is closed with the lower-outer flap, creating a duplication of the suture and covering it with the iliopsoas muscle and the gluteus medius muscle mobilized at the time of access.

A method of surgical access to the hip joint during endoprosthetics is known [Patent RU No. 2638426], aimed at reducing trauma, reducing the rehabilitation period due to faster restoration of the muscular environment and function of the hip joint. The authors propose to draw a central line in the direction from top to bottom above the greater trochanter. On this central line, the points of the proximal and distal borders of the greater trochanter are marked. The distance between these points is measured and divided into 3 equal parts, highlighting the proximal, middle and distal. The first incision is made from the proximal point along the muscle fibers of the middle gluteus muscle in the antero-superior direction with a length of 3 cm. The second incision is made from the point on the border between the middle and distal thirds of the greater trochanter in the anterior direction, stepping back from the central line by 1 cm, with a length of 3 cm. The third incision is made, connecting the starting points of the first and second incisions with each other, in the form of an arc directed with the convex side forward. The gluteus medius muscle is dissected from the anterior surface of the greater trochanter within the incisions made. The resulting flap of the gluteus medius muscle is displaced anteriorly and fixed with instruments.

The technology for performing this method is associated with significant damage to the connective and muscle tissue adjacent to the hip joint.

The technical result is the preservation of the integrity of the muscle tissues surrounding the hip joint and ensuring its functioning, the elimination of dislocations in the immediate postoperative period after total endoprosthetics.

The technical result is achieved as follows.

The patient is placed on his side, on the side of the healthy joint, in such a way as to ensure unimpeded access to the joint to be replaced. One support is installed in the area of the sacroiliac joint, the second - in the area of the pubic symphysis. The limb to be operated on is positioned parallel to the plane of the operating table with the help of rollers installed under the shin.

The operated limb is bent at the knee, pulling it towards the thigh so that the angle between the conditional projection of the midline of the thigh (2) and the axial plane of the body is 10-15 degrees.

A conditional coordinate system is determined, the center of which is the greater trochanter of the femur (1), from the projection of the center of which 4 cm are proximally and 2 cm dorsally. The skin and subcutaneous tissue are dissected (3) over a length of 14 cm parallel to the projection of the midline of the thigh (2) (Fig. 1).

The broad fascia of the thigh (4) is opened, and the projection of the sciatic nerve (5), which is usually located in the fatty sheath, is visualized (Fig. 2, 3).

The thigh is extended and maximally rotated inward, while the limb is bent at an angle of 90° at the knee joint, which allows visualization of the hip rotators: the piriformis (6), superior gemellus (7), and internal obturator (8) muscles (Fig. 4, 5).

Using the Homan retractor (12), the tendon of the piriformis muscle (6) is surgically mobilized over a distance of 2.5-3 cm from the piriformis fossa, and the piriformis muscle (6) is retracted ventrally.

Subperiosteally, the tendons of the superior (7) and inferior (9) gemellus muscles and the internal obturator (8) muscle are cut off.

The capsule is opened with a T-shaped incision, and a posterior dislocation of the head of the hip joint is performed (Fig. 5).

An awl with a limiter (14) is inserted into the head of the femur (10), a Homan retractor (12) is inserted under the femoral neck and, in accordance with preoperative planning, the head of the femur (10) is filed down.

The acetabulum (13) is visualized, the limb is extended at the hip joint and internal rotation is performed towards the foot by 10-15°. The Homan retractor (12) is installed in the area of the anterior wall of the acetabulum (13), two awls with a limiter (14) are installed in the area of its posterior edge, one at 2 o'clock on the conditional dial, the second at 22 o'clock on the conditional dial (Fig. 6).

The acetabulum (13) is processed with cutters (15), preparing it for implantation, and the acetabular component of the hip joint endoprosthesis and the polyethylene liner are sequentially installed.

Perform internal rotation of the thigh to an angle of 30-40°, bend the limb at the hip joint to an angle of 60-70°, thereby visualizing the proximal femur, install three Homan retractors (12) in the area of the greater trochanter (1), the area of the femoral head cut (10) and the anterior wall of the acetabulum (13). Visualize the attachment site of the piriformis tendon (6) in the area of the piriformis fossa (Fig. 8).

The femoral component spacer is installed, and the endoprosthesis head is tried on. Control passive movements in the hip joint are performed: abduction 35-45°, external rotation 40-50°, flexion 100-120°, extension 15°, thus assessing the absence of installation and internal rotation disorders of the joint.

The installation of the femoral component and the head of the endoprosthesis is completed, the piriformis muscle (6) is preserved (Fig. 9).

The joint capsule is sutured, a suture (16) is placed on the superior gemellus muscle (7), a suture (17) on the internal obturator muscle (8), a suture (18) on the inferior gemellus muscle (9). The proper fascia of the thigh and subcutaneous fat are sutured.

Algover skin suture, other suturing options are fraught with the development of ligature fistulas.

Thus, we have taken into account the following essential points in the sequence of performing the total hip arthroplasty operation: the use of a conditional coordinate system oriented towards the greater trochanter of the femur; mobilization of the piriformis muscle; a limited T-shaped incision of the hip joint capsule, which allows for clear visualization of the anterior edge of the acetabulum, while the functionality of the capsule is preserved; gentle flexion in the hip joint to an angle of 60-70° weakens the tension of the piriformis muscle, which allows for all its fibers to remain intact during any stage of the operation.

The proposed approach was tested on 12 patients who underwent total hip replacement surgery at the clinical base of the Federal State Budgetary Educational Institution of Higher Education Voronezh State Medical University named after N.N. Burdenko of the Ministry of Health of the Russian Federation at the Voronezh Regional Clinical Hospital No. 1. Dynamic observation of these patients for periods from six months to three years after the surgery confirms the absence of dislocations in the operated joint in the immediate postoperative period; according to the literature, the incidence of such a complication is 15%.

Clinical example of implementation

Patient K, 59 years old.

Admitted to the orthopedic department on January 18, 2023 with a diagnosis of idiopathic left-sided coxarthrosis stage 3, persistent pain syndrome.

Complaints: pain in the left hip joint (in the groin area on the right) at rest and during movement, pain in the gluteal region, knee joint when putting weight on the leg with irradiation to the left thigh, increasing after a short walk, starting pain. Night pain. Limitation of movement in the hip joint.

Considers himself ill since 2017, when pain in the left hip joint appeared. Significant pain in the left hip joint appeared in November 2020. Periodically underwent courses of conservative therapy in the local clinic without improvement. About six months ago, the pain in the left hip joint increased sharply. Assessment of hip function according to the Harris scale is 42.3%. Admitted for surgical treatment.

Clinical and expert anamnesis: does not work, no disability. By profession - milling machine operator.

Status specialis: walks independently with the help of a cane, antalgic gait on the right lower limb. Movements in the left hip joint are painful, limited due to pain. Range of motion: flexion 50°, external rotation 5°, internal rotation 10°. The lengths of the limbs are not equal. No neurotrophic disorders were detected at the time of examination.

On the radiographs of the left hip joint: the joint space is sharply narrowed; subchondral sclerosis, the bottom of the socket is 4.3 mm, marginal osteophytes of the roof, the head is of irregular shape.

Surgery was performed on 19.01.2023: total endoprosthetics of the left hip joint with a cementless endoprosthesis. Posterior access, according to the proposed method with preservation of the piriformis muscle.

The patient is placed on his right side, one support is installed in the area of the sacroiliac joint, the second in the area of the pubic symphysis. The left leg is positioned parallel to the plane of the operating table - a bolster is installed under its shin.

The knee of the left leg was pulled towards the thigh, the angle between the conditional projection of the midline of the thigh and the axial plane of the body was 15 degrees.

The projection of the greater trochanter of the femur onto the skin was visually identified, 4 cm proximally and 2 cm dorsally from its center, and a 14 cm long incision was made in the skin and subcutaneous fat, the incision being parallel to the projection of the midline of the thigh.

The broad fascia of the thigh was opened, the projection of the sciatic nerve was visualized. Then the thigh was extended and rotated towards the groin, the limb was bent at the knee joint at an angle of 90°, the hip rotators were visualized.

Using a Homan retractor, mobilize the piriformis tendon 3 cm from the piriformis fossa, retracting the piriformis muscle ventrally.

The tendons of the superior and inferior gemellus muscles and the internal obturator muscle were cut subperiosteally.

The hip joint capsule was incised with a T-shaped incision and the head of the hip joint was dislocated posteriorly.

An awl with a limiter was inserted into the head of the femur, a Homan retractor was inserted under the femoral neck, and the head of the femur was filed down.

The acetabulum was visualized, the left leg was extended at the hip joint, and internal rotation towards the foot was performed by 15°. A Homan retractor was installed in the area of the anterior edge of the acetabulum, and awls with a limiter at 2 o'clock and 22 o'clock of a conventional clock face were installed in the area of its posterior edge.

The acetabulum was processed with milling cutters, the acetabular component of the hip joint endoprosthesis and a polyethylene liner were installed.

Then the hip was rotated to an angle of 40° inwards, the limb was bent at the hip joint to an angle of 65° - the proximal part of the femur was visualized. Three Homan retractors were installed: in the area of the greater trochanter, in the area of the femoral head cut, in the area of the anterior wall of the acetabulum. The attachment site of the piriformis tendon was visualized.

The femoral component spacer was installed, the endoprosthesis head was tried on, and passive hip joint movements were performed: 40° abduction, 45° external rotation, 110° flexion, 15° extension. Movements were free, there were no endoprosthesis installation violations, joint rotation was in full. The femoral component and endoprosthesis head installation was completed.

The T-shaped incision of the joint capsule was sutured, rotators were sutured, the hip's own fascia and subcutaneous fat were sutured. Algover skin suture.

Surgical blood loss 250 ml.

Postoperative period: stood up with support on the first day after the operation, no complaints. Pain syndrome on the VAS scale on the 3rd day after the operation was 6 points, by the 8th day 4 points. Control examination after six months: no complaints, no pain syndrome, full self-care, no lameness. Harris scale assessment is 77%. Hip flexion angle is 115°.

Description of the figures

Figure 1. Skin access.

1. Greater trochanter of the femur;

2. Midline of the thigh;

3. Incision of the skin and subcutaneous fat.

Figure 2. The broad fascia of the thigh is visualized.

1. Greater trochanter of the femur;

4. Fascia lata of the thigh.

Figure 3. Visualization of the projection of the sciatic nerve.

5. Projection of the sciatic nerve.

Figure 4. Visualization of the hip rotators.

6. Piriformis muscle;

7. Superior gemellus muscle;

8. Internal obturator muscle;

9. Inferior gemellus muscle.

Figure 5. Dislocation of the femoral head.

10. Head of the femur;

11. Quadratus femoris;

12. Hohmann retractor.

Figure 6. Visualization of the acetabulum.

12. Homan retractor (placed on the anterior edge of the acetabulum);

13. Acetabulum;

14. Awl with a limiter.

Figure 7. Processing the acetabulum with milling cutters for implantation of the acetabular component.

12. Homan retractor (placed on the anterior edge of the acetabulum);

14. Awl with a limiter;

15. Cutter for processing the acetabulum.

Figure 8. Treatment of the femoral canal.

1. Greater trochanter of the femur;

6. Piriformis muscle;

12. Hohmann retractor.

Figure 9. The endoprosthesis is installed, the piriformis muscle is preserved.

6. Piriformis muscle.

Figure 10. Rotators are sutured.

16. Suture of the superior gemellus muscle;

17. Suture of the internal obturator muscle;

18. Suture of the inferior gemellus muscle.

Claims (1)

A method of access during total hip arthroplasty with preservation of the integrity of the piriformis muscle, including determination of the projection of the greater trochanter of the femur, opening of the broad fascia of the thigh and dissection of the obturator muscles, characterized in that the operated limb is bent at the knee, pulling it toward the thigh so that the angle between the projection of the midline of the thigh and the axial plane of the body is 10-15 degrees, the position of the greater trochanter of the femur is determined, from the projection of the center of which they retreat 4 cm proximally, 2 cm dorsally, the skin and subcutaneous tissue are dissected over a length of 14 cm parallel to the projection of the midline of the thigh; the broad fascia of the thigh is opened, the projection of the sciatic nerve is visualized; The Homan retractor is used to mobilize the tendon of the piriformis muscle over a distance of 2.5-3 cm from the piriformis fossa, the piriformis muscle is retracted ventrally; the joint capsule is opened with a T-shaped incision; the tension of the piriformis muscle is weakened by bending the limb at the hip joint to an angle of 70°.