Arthrotomy of the knee joint: surgery, indications, rehabilitation

Arthrotomy of the knee joint is a surgical tactic in which the joint capsule is dissected to expose (open) the joint cavity. In some sources, this surgical technique is called capsulotomy. The technique allows you to open the joint wide and perform its thorough sanitation along with the necessary therapeutic manipulations. Manipulations may include evacuation of pathological fluid from the knee, drainage, removal of foreign bodies and free osteochondral fragments, resection of non-viable tissue, administration of medications, etc.

Arthrotomy in surgical practice today is used in extreme cases, as it is characterized by high surgical aggression. In addition, modern orthopedics is predominantly based on minimally invasive principles of restoring the functions of the largest, most complex human joint. Many problems can be successfully solved by the gentle therapeutic and diagnostic procedure arthroscopy, which is done through small punctures in the knee. However, for performing large-scale interventions, such as removing a joint and installing a prosthesis, a small arthroscopic approach is not suitable. Therefore, in some situations there is no alternative to arthrotomy.

It can be used as an independent procedure or act as the initial stage of some complex orthopedic operation.

During arthrotomy, the specialist tries to preserve the ligamentous flexor-extensor apparatus of the knee as much as possible. Often it is impossible to do without cutting the ligaments, but this is done very sparingly so as not to significantly disturb the stabilization of the knee joint.

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Indications for surgery

Such radical intervention often becomes necessary if:

intra-articular suppuration in local tuberculosis, arthritis;
severe inflammation with voluminous accumulation of fluid;
severe post-traumatic hemarthrosis;
articular mouse (cartilage fragments, bone, dense fibrin clot);
complete separation or fragmentation of the meniscus;
serious injuries penetrating the joint;
congenital articulation defects;
bone dislocations requiring internal reduction;
fractures of the bones forming the joint;
avascular osteonecrosis;
various etiologies of progressive neoplasms;
gonarthrosis and ankylosis of advanced forms (after arthrotomy, arthroplasty or arthrolysis is performed).

The question of the need for traumatic surgery is decided individually. Sometimes, but only if the clinical picture allows, they first try to treat the affected segment conservatively. For example, they perform punctures for accumulated fluid, injections of the necessary medications into the joint with aseptic or metabolic effects, and so on. The ineffectiveness of non-surgical therapy and the inability to perform arthroscopy are grounds for prescribing arthrotomy of the knee joint.

Manual therapy in the treatment of bloat

Using manual therapy methods, it is possible to eliminate stagnation of lymphatic fluid in the inversions of the knee joints. Massage allows you to achieve timely outflow and intra-articular circulation. This eliminates the risk of developing an inflammatory process.

Osteopathy activates the microcirculation of lymphatic fluid, which starts the process of draining excess synovial fluid. Therapeutic gymnastics and kinesiotherapy normalize the intra-articular balance of cavity pressure and simulate communication between conjugate torsions. The circulation of synovial fluid stimulates reparative processes and eliminates tissue breakdown under the influence of toxins and accumulated metabolic products.

Acupuncture, laser therapy, and physiotherapy are used. The course of treatment is developed individually for each patient. If, during the examination, a pathology of torsion of the synovial membrane of the knee joint was revealed, we recommend that you consult an orthopedist as soon as possible. Timely treatment of this condition eliminates the risk of developing deforming osteoarthritis, as a result of which the mobility of the knee joint is completely lost.

Types of intervention

Types of surgical intervention differ in the technique of making incisions. In knee orthopedics, arthrotomy is based on 3 traditional approaches:

anterior internal/external parapatellar (according to Ollier, Langenbeck);
transverse (according to Textor);
posterolateral (according to Voino-Yasenetsky);

There is another principle for creating access, which combines the advantages of typical techniques. This is a paracondylar arthrotomy (according to Kornev), which makes it possible to widely expose the arch of the superior inversion on both sides, the joint cavity along the entire line of the joint space, and two posterolateral chambers. The Kornev incision provides access to all potentially dangerous areas, where often during pathological processes pus, effusion, and blood are concentrated and retained. Of course, the doctor will determine which technique is most rational to use only on the basis of reliable diagnostic results on the exact localization of the pathological focus.

Preparing for surgery

The operation requires pain relief, so the main type of anesthesia is general. If general anesthesia is contraindicated for health reasons, the issue of performing manipulations under regional spinal or epidural anesthesia is considered. After a preoperative examination by an orthopedist and consultation with an anesthesiologist, the patient is sent to undergo mandatory laboratory tests such as:

biochemical blood test;
clinical examination of urine;
syphilis test (RW);
hepatitis test;
HIV and AIDS testing;
coagulogram.

The planned procedure is always preceded by a kind of preparation of the surgical field and the entire leg for 5 days, which implies:

repeated washing of the limb with soap;
washing with diluted ammonia;
local application of aseptic dressing material at night.

In case of intra-articular purulent leaks, arthrotomy should be carried out against the background of an already started course of antibiotic therapy. It is recommended exclusively by a specialist, taking into account the performed test for the resistance of the pathogenic environment to the antibacterial composition.

Over the course of a few days, the patient visits several highly specialized specialists (therapist, cardiologist, phthisiatrician, etc.). It is mandatory to undergo examination by doctors specializing in concomitant chronic diseases: diabetics visit an endocrinologist, people with kidney diseases visit a nephrologist, etc.

Food and water intake is canceled 12 hours before the operation. Immediately before the arthrotomy, a cleansing enema will be given.

Technique for knee arthrotomy

As we have already said, arthrotomy is based on several tactics for exposing the articulation. Therefore, we will try to briefly outline the essence of each technique.

Anterior parapatellar capsulotomy
. The beginning of the skin incision is above the kneecap, approximately 8 cm from it, at the junction of the external thigh muscle and the quadriceps tendon. From this point, the skin is incised downward, following the outer line of the patella with a scalpel. The incision ends 20 mm below the tibial tuberosity. After the surgeon dissects the hypodermis and fascia along a given trajectory, the fibrous layer and synovial capsule are opened. Next, the necessary manipulations are carried out. This technique is not often used because it carries a high risk of injury to the common peroneal nerve.
Transverse method according to Textor
. A wider horseshoe-shaped incision is made, covering both sides of the joint. During its implementation, the patella's own ligament is crossed and the ligaments are dissected along the lateral surfaces of the articulation. A bilateral incision is made from a bent knee position 6 cm above the patella. It is guided down the end structures of the rectus femoris tendon and to the side of the kneecap. Having reached the lower pole of the patella, the incision is continued along the rounded protrusion of the condyle to the site of attachment of the collateral ligaments. A U-shaped incision is used to dissect the skin and fibrous joint membrane down to the synovial membrane. The synovial membrane is dissected parapatellar, after which the superior inversion is opened. The capsule is dissected retrocondylarly (downwards and backwards) together with the posterior inversions. Next, the main therapeutic actions begin; they usually involve large-scale resection of the joint.
Posterolateral arthrotomy
. It is used more often for purulent lesions (gonitis, epiema) of the joint. The osteochondral junction is opened using 4 incisions. First, two anterior parapatellar incisions are made, parallel to the two sides of the patella. Then the posterior inversions are opened using two longitudinal-lateral incisions. The posteromedial inversion is entered between the femoral condyle and the inner head of the gastrocnemius muscle, and the posterolateral inversion is entered through an incision above the biceps femoris tendon. Following strictly the operating procedure, the specialist pumps out the pus, introduces and installs drainage systems.

Surgical interventions are completed with careful hemostasis. The dissected areas of the synovial membrane and soft structures are sutured layer by layer with catgut threads. The skin edges are sutured with silk suture material. Finally, the leg is immobilized in the correct position with a plaster cast. A “window” is cut in the applied plaster, through which the surgical wound will be treated and bandaged.

Superior inversions of the knee joint

When performing an ultrasound or MRI, you can often see in conclusion that the superior inversion of the knee joint is widened or that there is fluid in it. What does this mean and how to carry out treatment correctly?

Normally, fluid in the superior inversion of the knee joint is present in limited quantities. This is due to the special location of the synovial canal. With the development of deforming osteoarthritis, the back pocket is primarily affected, so the shock-absorbing load is shifted to the upper inversion of the knee joint, which provokes excessive stretching of the cavity and accumulation of a large amount of fluid inside. This can lead to compression of the surrounding soft tissue, causing pain, swelling of the joint and limited mobility.

The superior anterior inversion of the knee joint, located above the knee, has a connection with the suprapatellar joint capsule. This allows him to equalize cavity pressure due to the outflow of fluid. However, if it accumulates excessively, a secondary form of suprapatellar bursitis may develop.

The quadriceps femoris tendon lies above this synovial recess. When it is injured, with subsequent scarring, partial displacement of the volvulus may occur with compression of other pockets of the synovial membrane.

The lateral and medial anterior inversions of the knee joint are located above along the lateral projections of the protruding parts of the condyles of the tibia and femur. They are connected to each other - liquid flow is possible. These formations are classified as extra-articular; they come into contact with the menisci and partially supply them with fluid. Connected to the superior patellar inversion.

The lower anterior ones are also divided into internal and external. They provide nutrition to the menisci from the lower surface. Closed by the infrapatellar body. Connected to the joint capsule of the same name.

Possible difficulties and problems

All types of arthrotomies of the knee joints, like any deep invasions of the anatomical parts of the body, can cause complications. Although not as common, consequences do occur in some patients, these include:

development of infectious processes in the wound area;
injury to neurovascular formations with instruments;
formation of a blood clot in the veins of the limb (phlebothrombosis);
separation and migration of a thrombotic clot with blockage of the pulmonary artery;
reflex dystrophy syndrome (pain reaction to extensive invasion);
inflammation of the synovium with accumulation of effusion;
hemorrhage in the knee joint;
allergy to the anesthesia used.

Lateral and medial lateral inversions

The lateral inversions of the knee joint are pockets that provide stability to the position of the tibial and femoral condyles. They reach the upper or lower surface of the menisci.

The medial inversion of the knee joint, located at the top, is covered by the lateral ligaments and muscle tendons. The lateral inversion of the knee joint is located symmetrically on the other side. The lower ones duplicate the upper ones. The lateral one covers the head of the fibula. The medial connects to the tibial condyle.

Basics of rehabilitation

Rehabilitation after knee arthrotomy is a fairly long process, since the operation is an intervention of medium complexity. Full recovery takes from 2 months to six months. In the early stages, each patient receives intensive treatment with antibiotics against wound infection and strong anti-inflammatory drugs for pain and swelling. Therapy with vascular drugs is prescribed to prevent thrombosis.

Causes of collateral ligament rupture

Isolated rupture of the lateral collateral ligament is extremely rare due to anatomical features and other typical mechanics of injuries. Typically, when the lateral collateral ligament is torn, the traumatic force is so great that it damages the so-called posterolateral complex, which includes the lateral collateral ligament, the popliteus tendon, and the posterolateral capsule of the knee. joint Although such injuries are, fortunately, rare, they occur among young patients when engaging in active sports associated primarily with the active use of the entire range of motion of the knee joint. Among these sports are game types: football, basketball, volleyball; extreme sports: alpine skiing, skydiving, parkour, bike trials and the like.

A rupture of the lateral collateral ligament or damage to the entire posterolateral complex cannot be overlooked. It is accompanied by a noticeable “click” or “crunch”, acute pain and limited ability to support. After some time, significant swelling occurs in the entire area of the injured knee joint.