Arthrotomy

Exposure of the joint and opening of its cavity is performed surgically, and this manipulation in orthopedic and trauma surgery is defined as arthrotomy, which can be performed with various surgical approaches. [1]

Indications for the procedure

The indications for arthrotomy are the need for any operation on the joints that requires access to their structures - for the surgical elimination of the patient's problems, in particular:

• fracture of the joint, which requires open reduction of bone fragments and their internal fixation in the correct position;
• rupture of ligaments - for their reconstruction;
• accumulation of purulent exudate in the joint capsule in inflammatory joint diseases. For example, arthrotomy for purulent arthritis or  synovitis of  any joint, purulent  bursitis of the knee joint , shoulder or elbow joints is performed to remove pus from the articular cavity - drainage when there is no improvement after arthrocentesis (intra-articular puncture).

Wide surgical access to the joint is indispensable:

• when removing osteophytes, fragments of bones and cartilage, intra-articular cysts or tumors;
• when excision of the synovial membrane is required -  joint synovectomy , which can be used in cases of rheumatoid and reactive arthritis, ostearthrosis, osteochondromatosis;
• in cases of intra-articular arthrodesis - artificial stabilization of the joint with its deformation or pathological mobility;
• with arthroplasty - restoration of joint mobility in patients with ankylosis or congenital articulation defects;
• if it is planned to install joint implants -  arthroplasty .

Preparation

As a rule, joint surgery is carried out in a planned manner, so all necessary examinations are carried out at the stage of identifying and determining the problems that patients have - clinical  diagnosis of joints  - and choosing a treatment strategy. Often, orthopedic surgery becomes inevitable in the absence of the effect of medication and physical therapy. [2]

Before an operation with arthrotomy performed in a hospital setting, preparation necessarily includes clarifying the state of a particular joint, for which its preoperative visualization is performed: X-ray, ultrasound, CT or MRI.

Also, patients take a general blood test; tests for hepatitis, RW and HIV; coagulogram  and  general clinical analysis of synovial fluid .

A week before the operation, you should stop taking anticoagulants, including those containing acetylsalicylic acid, and the last meal should be at least 10-12 hours before the operation.

Technique of the arthrotomy

The technique of performing this surgical manipulation depends on the specific diagnosis, the purpose of the intervention and the technique used by the surgeon to access various joints, which have their own characteristics of bone and ligamentous anatomy. [3]

To anesthetize the operation (taking into account its volume and localization), both general anesthesia and regional or local anesthesia are used.

Hip arthrotomy

For surgical drainage for septic arthritis of the hip joint or for performing synovectomy in cases of  synovitis of the hip joint,  such standard approaches are used as: Smith-Petersen arthrotomy - anterior (iliofemoral) approach; anterolateral Watson-Jones approach; posterolateral Langenbeck approach - with a soft tissue incision from the posterior superior iliac spine to the greater trochanter (tubercle at the top of the femur - Trochanter major) and opening the articular capsule by a T-shaped dissection.

In total hip arthroplasty, posterior, direct anterior and direct lateral approaches are common. For example, a direct lateral arthrotomy of the hip joint is an incision that the surgeon begins to make 3 cm closer to the middle third of the greater trochanter, continues along the line of the femur to its tubercle (a few centimeters short of it); an incision in the skin and subcutaneous tissue is made up to the Fascia lata (fascia lata of the thigh), which is also incised longitudinally in front of the lateral protrusion of the Trochanter major. Further, to get to the joint capsule, the gluteal muscles (m. Gluteus medius and m. Gluteus maximus) are exposed with their separation by blunt dissection at the level of the greater trochanter.

Knee arthrotomy

Depending on the diagnosis and the purpose of the surgery, knee arthrotomy can be performed using different techniques: according to Langenbeck, Tilling, Textor. [4]

So, arthrotomy according to the Textor is performed by a cross-section of an arcuate shape, which begins at one condyle of the femur and ends at the opposite - below the patella (patella), with the intersection of the patellar ligaments (Retinaculum patellae mediale and Ligamentum patellae).

Arthrotomy according to Voino-Yasenetsky or arthrotomy through the lateral parapatellar approach is performed with two longitudinal incisions on the sides of the patella.

In case of meniscus rupture, to remove the patella, as well as for total arthroplasty in cases of  osteoarthritis of the knee joint (gonarthrosis)  , medial parapatellar arthrotomy is used to access the joint. In this case, four incisions are made: two anterior longitudinal - on both sides of the patella, one through the lateral supporting ligament and another longitudinal - above the edge of the upper part of the patella to the middle of the border of the Tuberculum medialis (medial tubercle of the tibia). [5]

Ankle arthrotomy

Surgical fixation of a fracture with displacement in the area of the external or internal ankle is recognized as the most adequate surgical treatment that ensures normal biomechanics of the ankle joint after such injuries.

Surgical approaches for ankle arthrotomy: anterior (medial) and anterolateral, lateral and posterolateral.

With the anterior approach, the skin and subcutaneous tissue are dissected above the joint along the midline of the lower leg - along the tibial (os tibia) and fibula (os fibula) bones with a vertical dissection of the aponeurosis of the leg between the tendons of the long extensors of the fingers and big toe - with the isolation and protection of the branches of the peroneal nerve (cutaneous and deep), as well as the vessels of the dorsum of the foot. The incision can be made medial to the tendon of the anterior tibial muscle with its lateral abduction (together with the neurovascular bundle). Then the joint capsule is incised and the joint is exposed.

Lateral arthrotomy of the ankle joint is performed by an incision in front or behind the lateral edge of the fibula with its continuation between the muscles of the lower leg - m. Peroneus tertius (fibular) and m. Peroneus longus (long fibula).

Arthrotomy with posterior access - through an incision along the posterolateral border of the calcaneal (Achilles) tendon to the point of its attachment to the calcaneus; two longitudinal incisions can also be made - on both sides of the Achilles tendon. The application of this technique gives the surgeon access to the distal end of the tibia, the posterior ankle, the posterior end of the talus, and the talocalcaneal joint.

Shoulder arthrotomy

Opening the joint cavity for drainage, according to clinical experience, is a more effective method of treating septic arthritis of the shoulder joint, and arthrotomy is also used in cases of chronic or  habitual shoulder dislocation .

Anterior arthrotomy of the shoulder joint (according to Langenbeck) or deltopectoral approach is performed by an incision, which starts from the anterior surface of the lateral end of the scapula (acromion), then descends by about 8 cm along the anterior edge of the middle bundle of the deltoid muscle of the shoulder (m. Deltoideus) - with dissection of the fascia ( to the articular tendon) and dividing the muscle by blunt dissection. The bursa is exposed after stretching the muscle fibers and dissecting the caput longum (long head) of the biceps brachii that passes through the shoulder joint.

Access to the shoulder joint can be anterolateral, when the incision also starts from the acromion, but then goes down along the inner edge of the biceps brachii muscle - along its medial groove (sulcus bicipitalis medialis).

Elbow arthrotomy

During arthrotomy of the elbow joint according to Langenbeck's technique, soft tissues on the dorsum of the joint are cut longitudinally - from the lower third of the humerus (humerus) to the upper third of the forearm; the process of the ulna (olecranon) is transected and the medial epicondyle of the humerus is cut off.

Arthrotomy can be performed by a dissection between the posterior muscle of the forearm - the extensor carpi ulnaris (m. Extensor carpi ulnaris) - and the ulnar muscle (m. Anconeus). The incision is made along a line connecting the lateral epicondyle of the humerus and the border between the proximal and middle third of the ulna (ulna). The incision is stretched and the common fascia of the wrist extensor is cut; the tendon of the upper part of the ulnar muscle is exposed, the origin of the ulnar extensor of the wrist is disconnected from the lateral epicondyle and the muscles are pulled back to expose the anterolateral surface of the articular capsule. It is incised along the anterior edge of the collateral collateral ligament of the elbow (collaterale radiale) - from the lateral epicondyle to the annular ligament of the radial bone.

Contraindications to the procedure

There are such contraindications for performing arthrotomy, such as:

• infectious and acute inflammatory diseases with fever;
• exacerbation of chronic diseases;
• infections of the tissues surrounding the joint;
• thrombocytopenia and decreased blood clotting;
• severe heart and pulmonary failure;
• deep vein thrombophlebitis - with interventions on the joints of the lower extremities.

Consequences after the procedure

The consequences of this operation include:

• development of inflammation of the inner shell of the articular bag - synovitis;
• the formation of blood clots in the veins of the lower extremities;
• gradual formation of ossificates in the soft tissues adjacent to the operated joint;
• skin necrosis due to deterioration of blood supply in the area of surgery;
• muscle tissue atrophy;
• joint contractures and limitation of their mobility due to fibrous adhesions and scars.

With arthrotomy of the knee joint, there is a risk of damage to the branches of the common peroneal nerve and popliteal branches of the saphenous nerve with the development of a postoperative tumor - neuroma. In addition, during this operation - due to too strong stretching of the joint capsule and surrounding tissues - it is possible for the patella tendon to come off the tibia. [6]

Complications after the procedure

As with any surgical procedure, there can be complications following arthrotomy, including:

• infection of a surgical wound with the development of an inflammatory process;
• an allergic reaction to anesthesia;
• prolonged or persistent pain around the joint.

Complications after arthrotomy can be in the form of hematoma of the periarticular tissues, they can also be associated with damage to blood vessels (with bleeding) or nerve branches. For example, as a result of exposure of the shoulder joint, there is a risk of alteration of the posterior circumflex brachial artery or nerves - suprascapular or axillary. [7]

Care after the procedure

After arthrotomy, care consists in splinting the operated joint (during surgery on the shoulder or elbow joint, it is possible to use an immobilizing orthosis), antiseptic treatment of postoperative sutures, prescribing antibacterial, anti-inflammatory, analgesic, thrombolytic and decongestant drugs.

The duration of immobilization depends on both the initial diagnosis and the extent of the operation. [8]

Rehabilitation after arthrotomy is a rather lengthy process with obligatory physiotherapy exercises and various physiotherapeutic procedures. The degree to which the joint is restored to its normal range of motion varies with the condition of each patient.