RU2834381C1 - Method for hip replacement from anterior mini-invasive approach - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology and orthopaedics, and can be used in hip replacement surgery for hip replacement from an anterior mini-invasive approach. Patient is placed on a surgical table on a healthy side so that the operated limb lies along the body. Approach is carried out by incising skin and subcutaneous fat 6-10 cm long from point located 2-3 cm caudal and 2-3 cm lateral from an anterior superior iliac spine parallel to fascia lata of muscle fibres. Fascia lata is visualized. It is stratified in the direction of the skin incision. Boundaries of muscle straining fascia lata are visually divided into equal parts and stratified along fibres. Lateral and medial surfaces of the femoral neck are palpated and Hohmann retractors are placed behind them. An L-shaped incision is performed and a medial and upward displacement of the hip joint capsule is performed after visualizing the anterior surface of the femoral neck; the femoral neck is sawed off with an oscillatory saw. Further, the next sawing of the femoral neck is made 1-1.5 cm proximally. Resected sector of the femoral neck is removed. Femoral head is removed with the help of an extractor, and retractors are installed.

EFFECT: method provides reducing traumatisation of all soft-tissue structures of the hip joint area with reduced pain syndrome due to the patient's position on the healthy side when the operated extremity lies along the body and the access to the hip joint is performed by blunt fibre dissection of the muscle straining the fascia lata.

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Description

Field of technology

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

State of the art

Osteoarthritis is one of the most common diseases of the musculoskeletal system. Around 10% of the population worldwide suffers from this pathology, which is the main source of pain, disability and socio-economic costs. Around 300 million cases are due to arthrosis of the hip and knee joints [1, 2, 3].

Hip replacement is the most effective method of treating osteoarthrosis of the hip joint. To perform this operation, posterolateral and anterolateral approaches are mainly used due to their maximum study and mastery. But these access options are accompanied by partial or complete muscle dissection, as well as significant disruption of the blood supply to the hip joint, which leads to disruption of soft tissue trophism.

Based on this, the search for a way to reduce trauma to muscles and ligaments, preserve trophism and innervation is logical and natural in the development of hip joint endoprosthetics technologies. A promising solution to this issue was the use of anterior minimally invasive access. The essence of this access is that anatomical intermuscular spaces are used for hip joint endoprosthetics without cutting off muscles from the attachment site. This allows reducing pain in the early postoperative period, as well as shortening the rehabilitation period.

The negative side of the existing variants of this approach is damage to the muscle that tenses the broad fascia and trauma to the lateral cutaneous nerve of the thigh [4, 5, 6, 7].

Disclosure of invention

The technical problem that the proposed solution is aimed at solving is minimal trauma to all soft tissue structures of the hip joint area with a reduction in pain syndrome in the postoperative period, a shortening of the rehabilitation period and a reduction in the duration of hospitalization for patients.

The technical result of the claimed invention consists in minimal traumatization of all soft tissue structures of the hip joint area with a reduction in pain syndrome due to the patient's position on the healthy side, when the operated limb lies along the body and access to the hip joint is achieved by blunt dissection of the fibers of the muscle that tenses the broad fascia.

The technical result of the claimed invention is achieved in that a method is proposed for performing hip joint endoprosthetics from an anterior minimally invasive approach, characterized by the fact that the patient is placed on the surgical table on the healthy side so that the operated limb lies along the body, access is performed by incision of the skin and subcutaneous fat 6-10 cm long from a point located 2-3 cm caudal and 2-3 cm lateral from the anterior superior iliac spine parallel to the broad fascia of the thigh of the muscle fiber dissection, the broad fascia of the thigh is visualized, dissected in the direction of the skin incision, the boundaries of the muscle tensor of the broad fascia of the thigh are determined, which is visually divided into equal parts and dissected along the course of the fibers, the lateral and medial surfaces of the femoral neck are palpated and Hohmann retractors are installed behind them, an L-shaped dissection and medial and upward displacement of the hip joint capsule are performed after visualization of the anterior the surface of the femoral neck is sawed with an oscillating saw, then 1-1.5 cm proximally the next saw is made on the femoral neck, after which the resected sector of the femoral neck is removed, the head of the femur is removed with an extractor, and retractors are installed.

The combination of the above essential features leads to the fact that:

possible intra- and postoperative complications that arise when using the anterior approach are minimized, thereby improving the function of the hip joint and shortening the rehabilitation period for patients;

the implementation of the proposed approach by blunt dissection of the muscle tensor fascia lata of the thigh allows for a reduction in the load on the muscle during manipulations in the wound while maintaining a good view, and ensures an optimal angle of inclination of the axis of the surgical action;

The release of the iliofemoral ligament allows the proximal femur to be brought out for comfortable and safe preparation of the femoral component bed.

Brief description of the drawings

The essence of the invention is explained by figures, where

Figure 1 shows the patient positioned on his side. The patient lies on a standard orthopedic table. Landmarks are marked: greater trochanter, anterior superior iliac spine. The access and borderline are also marked.

Figure 2 shows the appearance of the surgical wound when accessing the hip joint through the middle of the tensor fascia lata muscle using blunt dissection.

Figure 3 shows the appearance of the surgical wound when accessing the hip joint after filing and removing the head of the femur.

Figure 4 shows the position of the limb during proximal femur treatment. The assistant holds the limb being operated on in extension, adduction, and external rotation.

Figure 5 shows the appearance of the surgical wound when performing the release of the iliofemoral ligament during treatment of the proximal femur (shown by the dotted line).

Figure 6 shows a view of the surgical wound. The figure depicts intact soft tissues after the endoprosthesis has been installed using the described method before suturing the wound.

Figure 7 shows an X-ray of the hip joint before surgery.

Figure 8 shows an X-ray of the hip joint after total hip replacement surgery, performed using the original anterior approach.

Implementation and examples of implementation

The method is performed 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. Standard treatment of the surgical field with antiseptic solutions is performed. The surgical field is delimited by sterile linen so that the operated limb remains mobile Fig. 1. An incision of the skin and subcutaneous fat is made 6-10 cm long (depending on the severity of the subcutaneous fat) from a point located 2-3 cm caudal and 2-3 cm lateral from the anterior superior iliac spine parallel to the broad fascia of the thigh. After dissection and visualization of the broad fascia of the thigh, the latter is stratified in the direction of the skin incision. Then the boundaries of the muscle tensor of the broad fascia of the thigh are determined, which, visually divided into conditionally equal parts, is stratified along the course of the fibers Fig. 2. The surgeon palpates the lateral surface of the femoral neck and places the Hohmann retractor behind it. The Hohmann retractor is placed behind the medial surface of the femoral neck in a similar manner. These techniques result in the hip joint muscle displacement laterally and medially, and the anterior surface of the hip joint capsule is visualized. The latter is dissected L-shaped (leaving 0.5 cm at the base of the neck for subsequent refixation) and shifted medially and upward. After visualizing the femoral neck with an oscillatory saw, it is filed down in accordance with the preoperative preparation. Next, the femoral neck is filed down 1-1.5 cm more proximally. The resected neck sector is removed, thereby allowing the femoral head to be removed without technical difficulties using an extractor. Next, retractors are placed behind the edges of the acetabulum, the bed is prepared, and the acetabular component is installed (Fig. 3. To treat the medullary canal, the lower limb is moved into a position of extension, external rotation and adduction Fig. 4. Performing the release of the iliofemoral ligament allows, without additional trauma, to install retractors and bring the proximal femur into the wound Fig. 5. The medullary canal is successively treated with rasps, and the femoral component is installed into it. After the endoprosthesis head has been reduced, the joint retains a virtually “natural” anatomy and stability by preserving the anatomical integrity of the muscles in the hip joint area. Next, the joint capsule is refixed to its anatomical location, thereby achieving joint tightness. The wound is sutured layer by layer Fig. 6.

The proposed method requires a standard set of instruments to perform endoprosthetics surgery. The use of minimally invasive instruments allows for a shorter surgery time.

This solution, due to minor trauma to soft tissues, allows for early painless activation of patients in the postoperative period, which significantly improves the quality of life and ensures a speedy return to the usual level of physical and social activity, and restoration of working capacity.

Between September 2021 and January 2024, the applicant organization performed 527 surgeries using the proposed method. A biomechanical and clinical assessment of the endoprosthetics results was carried out. All patients noted lower pain intensity after surgery (on average, the VAS score was 2.3 points versus 5.5 after using standard surgical approaches) and were able to walk with full weight-bearing on the leg on the first day after surgery. During this period, the functional index according to the Harris scale averaged 85.3 points, compared to 33.7 in the lateral approach group. Thus, the analysis of the immediate results of endoprosthetics confirms an improvement in hip joint function and earlier recovery of patients after using the proposed method.

Clinical example of the method implementation

Patient S., 38 years old, diagnosed with left-sided coxarthrosis stage 3. Fig. 7, underwent surgical treatment using the proposed approach in the Department of Traumatology and Orthopedics. On October 12, 2022, the operation was performed:

Total hip arthroplasty of the left hip joint. A standard operating table and 2 lateral rests were used to fix the patient in the lateral position. A set of curved Hohmann retractors was used. Standard treatment of the surgical field with antiseptic solutions was performed. The surgical field was limited by sterile linen so that the operated limb remained mobile. An 8-cm incision of the skin and subcutaneous fat was made from a point located 2 cm caudal and 2 cm lateral to the anterior superior iliac spine parallel to the broad fascia of the thigh. After dissection and visualization of the broad fascia of the thigh, the latter was dissected in the direction of the skin incision. The boundaries of the muscle tensor of the broad fascia of the thigh were determined, after which it was dissected along the course of the fibers into approximately equal parts. The lateral surface of the femoral neck was determined by palpation, and a Hohmann retractor was installed behind it. A Hohmann retractor was installed in a similar manner behind the medial surface of the femoral neck. An L-shaped dissection of the joint capsule was performed. After visualizing the femoral neck with an oscillating saw, it was filed down. Next, the femoral neck was filed down 1-1.5 cm proximally. The resected neck sector was removed, then the femoral head was removed without technical difficulties using an extractor. Retractors were installed behind the edges of the acetabulum, the bed was prepared and the acetabular component was installed. To treat the medullary canal, the lower limb was brought into a position of extension, external rotation and adduction. A release of the iliofemoral ligament was performed, which made it possible to install retractors and bring the proximal femur into the wound. The medullary canal was successively treated with rasps, and the femoral component was installed into it. The head of the joint endoprosthesis was reduced. Next, the joint capsule was refixed to the anatomical attachment site, and the joint was hermetically sealed. The wound was sutured layer by layer. The operation took 45 minutes, and the blood loss was 100 ml. In the early postoperative period, the patient was allowed to walk with crutches with full weight-bearing on the operated limb for 5 days. Upon discharge, she was allowed to give up one crutch. On the 10th day after the operation, the pain level on the VAS scale was 2 points (Fig. 8).

Thus, as a result of using this method, unlike other access options, there is no trauma to the branches of the artery and vein that encircle the femur, and the risk of trauma to the lateral cutaneous nerve of the thigh is reduced.

Sources of information:

1. Bhaskar, D. Current concepts in acetabular positioning in total hip arthroplasty / D. Bhaskar, A. Rajpura, T. Board // Indian journal of orthopedics. - 2017. - Vol.51. - P. 386-396.

2. Hunter, D.J. Osteoarthritis / D.J. Hunter, S. Bierma-Zeinstra // Lancet. - 2019. - Vol.393. - No. 10182. - P. 1745-1759.

3. Prietzel, T. The impact of capsular repair on the dislocation rate after primary total hip arthroplasty: a retrospective analysis of 1972 cases / T. Prietzel, N. Hammer, S. Schleifenbaum, D. Adler, M. Pretzsch [et al.] // Zeitschrift Fur Orthopadie und Unfallchirurgie. - 2014. - Vol.152. - No. 2. - P. 130-143.

4. An, S. Femoral artery injury during total hip arthroplasty / S. An, H. Shen, M. Feng, Z. Li, Y. Wang [et al] // Arthroplasty Today. - 2018. - Vol.4. - No. 4. - P. 459-463.

5. Marongiu, G. Acute common femoral artery lesion after direct anterior approach for THA. A case report and literature review / G. Marongiu, S.

Rigotti, A. Campacci, C. Zorzi // Journal of Orthopedic Science. - 2019. - Vol 24. - No. 2. - P. 382-384.

6. Mortazavi, S.M.J. Femoral artery intimal injury following total hip arthroplasty through the direct anterior approach: a rare but potential complication / S.M.J. Mortazavi, M. Kazemi, M. Noaparast // Arthroplasty Today. - 2019. - Vol.5. - No. 3. - P. 288-291.

7. Patton, R.S. Femoral neuropathy following direct anterior total hip arthroplasty: an anatomic review and case series / R.S. Patton, R.P. Runner, D. Lazarus, T.L. Bradbury // Journal of Surgical Case Reports. - 2018. - Vol.2018. - No. 9.

Claims (1)

A method for performing hip joint endoprosthetics from an anterior minimally invasive approach, characterized by the fact that the patient is placed on the surgical table on the healthy side so that the operated limb lies along the body, access is performed by incision of the skin and subcutaneous fat 6-10 cm long from a point located 2-3 cm caudal and 2-3 cm lateral from the anterior superior iliac spine parallel to the broad fascia of the thigh of the muscle fiber dissection, the broad fascia of the thigh is visualized, dissected in the direction of the skin incision, the boundaries of the muscle tensor of the broad fascia of the thigh are determined, which is visually divided into equal parts and dissected along the course of the fibers, the lateral and medial surfaces of the femoral neck are palpated and Hohmann retractors are installed behind them, an L-shaped dissection and medial and upward displacement of the hip joint capsule are performed after visualization of the anterior surface of the femoral neck, filing is performed the femoral neck with an oscillating saw, then 1-1.5 cm proximally the next sawing of the femoral neck is performed, after which the resected sector of the femoral neck is removed, the head of the femur is removed with an extractor, and retractors are installed.