RU2363404C2 - Method of kneecap medialisation during endoprosthesis of knee joint - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves layer by layer longitudinal dissection of soft tissue, ligamentous apparatus and capsule on its outer edge outside the kneecap, movement of the straight muscle together with the kneecap medially, sealing the capsule excess on the inner surface with overlapping, with formation of duplicatures, fixing the straight muscle to muscles of the anterointernal surface of the thigh. The joint capsule is laterally released. Passive maximum permissible bending and unbending movements of the limb operated on are done intraoperatively, and the amplitude of displacement of the kneecap is determined by measuring its position relative the intercondylar line, in accordance with which sealing is done. The straight muscle is only fixed to the medial vastus muscle in the region of the medial support patellar ligament, brought down diastally and to the outside, and is fixed to the chorda of rectus muscle of thigh. The medial vastus muscle is further split in the region of the medial support patellar ligament, brought down diastally and to the outside, and fixed to the chorda of rectus muscle of thigh.

EFFECT: restoration of anatomical centering of the kneecap in the intercondylar line at rest and during motion.

4 cl, 1 ex

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used in traumatology and orthopedic departments of hospitals and clinics of NIITO and high-tech centers for the treatment of patients with dislocations of the patella of various genesis and the resulting instability of the knee joint, as well as for the prevention of instability in the emerging lateral position of the patella during knee replacement.

A known method of treating dislocation of the patella [US Pat. RU No. 2099018, АВВ 17/56 dated 1993.12.28, publ. 1997.12.20], including mobilization of one’s own ligament by cutting it along the outer edge, holding an allograft behind it, tension in the medial direction with fixation on the inner condyle of the tibia, which prevents the relapse of dislocation.

The disadvantages of this method are:

- the inability to control the correction of the position of the patella;

- the need for tendon-muscle allografts;

- the possibility of use only if the integrity of its own ligament of the patella;

- the problematic use of knee arthroplasty.

A known method of surgical treatment of congenital dislocation of the patella [US Pat. RU No. 2262317, АВВ 17/56 dated 2000.07.19, publ. 2001.10.10], including mobilization of the tendon of the rectus femoris muscle, mobilization of the patella and its ligament with cutting off the latter from the attachment site, cutting out two grafts, the first from the tendon of the rectus femoris muscle, the second from the fibrous capsule of the knee joint from the inside, conducting transplants through the inner edge of the patella, the fixation of the grafts intraosseously to the inner condyle of the thigh, the displacement of the ligament of the patella inward by 1.5-2 cm and the fixation of it periosteally to the tibia without damage to the sprout th zone. The method allows to increase the strength of fixation, to prevent complications, relapses.

The disadvantages of this method are:

- the inability to control the correction of the position of the patella;

- the possibility of use only if the integrity of its own ligament of the patella;

- the problematic use of knee arthroplasty.

The closest in purpose and combination of essential features is the method of medialization of the patella when it is dislocated according to Friedland [p.157, GP Kotelnikov, applicable for knee replacement). Chernov A.P. Izmalkov S.N. Instability of the knee. - Samara: Samara Press House, 2001; p.233, Movshovich I.A. Operative orthopedics. - M. Medicine, 1983], including a layered longitudinal dissection of the soft tissues and ligamentous apparatus along the outer edge of the capsule of the knee joint, dissection of the joint capsule from the outside of the patella, separation of the rectus muscle of the thigh and tendon from the broad muscles, medial movement of the rectus muscle with the patella, suturing of the excess capsule along the overlap with the formation of duplicate, fixation of the rectus muscle by separate interrupted sutures to the tailor, large adductors and internal broad muscles in the knee flexion position stava at 90 ° -100 °, while holding the patella in the correct position.

The disadvantages of this method are:

- the risk of muscle ischemia and joint degeneration due to sewing immediately to three different muscles with multidirectional action vectors;

- dissection of the capsule only on the outer surface does not allow us to assess the degree of displacement of the patella during movements and determine the optimal amount of correction;

- a high risk of recurrence of functional instability of the extensor apparatus of the knee joint due to the continued constant effect of the "tensile" force of the quadriceps muscle with its insufficiently strong fixation;

- inadequacy of the control correction of the position of the patella;

- the problematic use of knee arthroplasty.

The problem solved by the invention:

- restoration of the anatomical centering of the patella in the intercondylar sulcus at rest and during movements, especially with its emerging lateral position during knee replacement.

The risk of knee dislocation and its instability is reduced, especially after knee replacement. As a result, the patient's quality of life improves. Additionally, the morbidity and complexity of the surgical intervention is reduced. There is no need for additional stabilizing surgical interventions and for endoprosthetics of the knee joint.

To accomplish the tasks in the proposed method for the medialization of the patella during knee joint replacement when performing a layered longitudinal dissection of the soft tissues, ligamentous apparatus and capsule along its outer edge outside the patella, moving the rectus muscle together with the patella medially, suturing the excess capsule along the overlap with the formation of duplicates, fixation of the rectus muscle to the muscles of the anterior-inner thigh, in contrast to the prototype, additionally perform latera ln release (notches for loosening) of the joint capsule, passively intraoperatively perform the maximum permissible flexion and extension movements of the operated joint and determine the amplitude of the displacement (degree of lateralization) of the patella by changing its position relative to the intercondylar groove, in accordance with which suturing is performed, the rectus muscle is fixed only to the medial wide portion of the quadriceps femoris. Additionally, the inner abdomen of the quadriceps femoris is cut off in the region of the medial support ligament of the patella, distally and outwardly, and fixed to the tendon of the rectus femoris muscle. The release of the anterior external capsule is performed from within the joint. In this case, release from the inside of the joint is performed no deeper than the top sheet of the patellar ligament, sequentially dissecting the synovial membrane first, then, if necessary, the joint capsule, and then adjacent tissues. If the patella is additionally displaced outwardly, the capsule is dissected parapatellarly for 50-70 mm.

The proposed method allows you to go to a new level and quality of treatment for patients with instability of the knee joint, with a dislocation of the patella and / or with its latent position when total knee arthroplasty is performed due to the controlled correction of the position of the patella, which allows avoiding both overgrowth of the capsule and loosening of the knee joint, as well as the formation of its stiffness and contracture. The method is pathogenetically justified as it provides not only the correction of the abnormal position of the patella and the rectus femoris muscle, but also the implementation of this correction by the most physiological method by reducing the inner abdomen of the quadriceps muscle during movements and eliminating muscle ischemia during fixation to multidirectional muscles.

The method is carried out in the following sequence.

The operation is performed under anesthesia or epidural anesthesia in the position of the patient on the back. Access is as follows: the skin and subcutaneous tissue are dissected by a direct longitudinal section from the upper pole of the patella to the inner surface of the tibial tuberosity. The upper leaf of the patellar ligament and capsule are dissected medially by a parapatellar incision. After installing the components of the knee endoprosthesis, control of movements is performed: flexion-extension with an assessment of the position of the patella in the intercondylar groove. Estimate the amplitude of its displacement. With the tendency of patellar displacement to the outside, release (relaxation) of the capsule is performed by dissecting parapatellarly from the inside of the anterior outer part of the capsule over a length of 50-70 mm. Moreover, during the release, either only the synovial membrane or the synovial membrane with the capsule to various depths, as necessary, is dissected. Then, the inner abdomen of the quadriceps femoris is cut off in the area of the medial support ligament of the patella, is reduced distally and outwardly and fixed to the tendon of the rectus femoris muscle. The capsule on the medial surface is sutured with overlap, double stitches with lavsan threads. The incision of the capsule on the outer surface is not sutured, the tightness of the joint is provided by the upper leaf of its own patellar ligament.

Example 1. Patient Z. 40 years old, case history No. 7706, disabled person of group 2, 08/14/2005 was admitted to the clinic with a diagnosis of Multiple epiphyseal dysplasia, bilateral secondary gonarthrosis of the 4th stage, condition after hip replacement, functional insufficiency of the 2nd degree. From the anamnesis: I’ve been sick since childhood, took non-steroidal anti-inflammatory drugs, chondroprotectors for a long time, received physiotherapeutic and spa treatment. In 2004 she underwent hip replacement with a good long-term result.

Hospitalized in a planned manner for arthroplasty of the right knee joint. After clinical, laboratory and X-ray examination, on August 18, 2005, the patient underwent an operation of total cement arthroplasty of the right knee joint with an STRYKER model of Scorpio with back stabilization.

Brief description of the operation: the skin and subcutaneous tissue are dissected by a direct longitudinal section along the front surface of the knee joint, the beginning of the section 12 cm above the joint gap, the end below the tuberosity of the tibia by 5 cm. After mobilization of the edges of the wound, a shift of the patella outward and posterior by 4 cm was revealed. The joint cavity is opened by medial parapatellar access. After installing the components of the endoprosthesis according to the standard method, an external release was made with a lateral parapatellar incision 7 cm long, which allowed the patella to be moved inward. When controlling movements by maximum flexion and extension, the amplitude of the displacement of the patella relative to the intercondylar sulcus was determined and a tendency toward the displacement of the patella outward was noted. The distal part of the inner abdomen of the quadriceps femoris is cut off in the region of the medial support ligament of the patella. The joint capsule along the inner surface is overlapped with double lavsan sutures. The severed inner abdomen was displaced down and outward and sutured to the tendon of the rectus femoris muscle. With a second control of movements, a satisfactory centering of the patella was noted without a tendency to lateral displacement. The incision of the capsule on the outer surface was not sutured. Subcutaneous tissue and skin are traditionally sutured. The early postoperative period was uneventful. The patient was discharged on the 10th day after the operation, skin sutures were removed on the 14th day on an outpatient basis.

During the follow-up examinations of the patient after 2 and 6 months, there is no pain in the right knee joint, the joint is stable, range of motion: extension - 0 °, flexion - 115 °. The patient plans endoprosthetics of the left knee joint.

Medical and social effectiveness of the method is:

- in reducing the cost of treating the knee joint;

- in the earlier restoration of the supporting and motor functions of the limb;

- in improving the functional results of treatment;

- in improving the quality of life of patients.

Claims (4)

1. The method of medialization of the patella during knee replacement, including layered longitudinal dissection of the soft tissues, ligamentous apparatus and capsule along its outer edge outside the patella, medial movement of the rectus muscle together with the patella, suturing the excess capsule along the lap surface with overlap formation, direct fixation muscles to the muscles of the anteroposterior thigh, characterized in that they perform lateral release of the joint capsule, passively maximize intraoperatively the most permissible flexion and extension movements of the operated limb determine the amplitude of the patella displacement by changing its position relative to the intercondylar sulcus, according to which suturing is performed, and the rectus muscle is fixed only to the medial broad muscle of the thigh in the region of the medial support ligament of the patella, lower distally and outward, fix to the tendon of the rectus femoris muscle, additionally cut off the medial broad muscle of the thigh in the region of the medial support ligament of the patella, bottom odyat distally and outwardly, is fixed to the tendon of the rectus femoris. 2. The method according to claim 1, characterized in that the lateral release of the capsule is performed from within the joint. 3. The method according to claim 2, characterized in that the release from the inside of the joint is performed no deeper than the wide fascia, sequentially dissecting the synovial membrane first, then, if necessary, the joint capsule, then adjacent tissues. 4. The method according to claim 1 or 3, characterized in that the capsule is dissected parapatellarly for 50-70 mm