Patent Publication Number: US-2005119697-A1

Title: Method of table mounted retraction in hip surgery

Description:
CROSS REFERENCE TO RELATED APPLICATIONS  
      This application is a continuation-in-part of application Ser. No. 10/728,202 filed on Dec. 4, 2003, which is hereby incorporated by reference in its entirety, which is a continuation of application Ser. No. 10/077,693, filed Feb. 15, 2002, which is incorporated by reference in its entirety, and resulting in U.S. Pat. No. 6,659,944, which is a continuation of application Ser. No. 09/990,420 filed on Nov. 21, 2001, which is incorporated by reference in its entirety, and resulting in U.S. Pat. No. 6,368,271.  
      This application is also a continuation-in-part of application Ser. No. 10/892,816 filed on Jul. 16, 2004, which is hereby incorporated by reference in its entirety, which is a continuation-in-part of application Ser. No. 10/623,179; filed Jul. 18, 2003, which is hereby incorporated by reference in its entirety, which claims priority of U.S. Provisional Application No. 60/396,850, filed Jul. 18, 2002, the content of which is hereby incorporated by reference in its entirety. 
    
    
     BACKGROUND OF THE INVENTION  
      The present invention relates to a method of surgical retraction. In particular, the present invention relates to a method of utilizing a table mounted retracting device during a surgical procedure on a hip of a patient.  
      Total hip replacement (arthroplasty) operations have been performed since the early 1960&#39;s to repair hip components. These components include the acetabulum (socket portion of the hip) and the femoral head (ball portion of the hip). The hip is typically replaced due to a gradual deterioration of the cartilage that cushions the bones within the joint. The surrounding structures in the hip can become inflamed and painful. Eventually, bone can begin to rub against bone causing severe discomfort.  
      Surgical procedures have been the most successful method to alleviate this pain. Either partial or total hip replacement surgery can be used. In total hip replacement, a cup shaped insert typically manufactured of polyethylene is inserted in place of the acetabulum, and a metal femoral head is placed in the femur. A number of variations have evolved in the surgical approaches and techniques used for replacement of the hip components, including operating while the patient is on his or her back (supine) or on his or her side (lateral). To a large extent, the choice of surgical approaches is due to the surgeon&#39;s preference as to what aspect of the hip components the surgeon wishes to view. The ability to view the surgical site is complicated by the need to remove the femoral head from the acetabulum as well as rotate and retract the femur in the wound during surgery.  
      The surgical procedure can become quite physically taxing on the surgeon or surgeons performing it. The surgical procedure requires lifting and moving the patient&#39;s femur into multiple positions. At times, the surgeon may need to hold the femur in position for an extended period of time. Depending on the size of the patient, the strenuous activity can lead to fatigue and contribute to surgical error. Additionally, the repeated movement of the leg can cause nerve damage if it is not done precisely and with minimal adjustment. When the surgeon moves the femur by hand it is common to have continual adjusting occur. Often, the surgeon holding the leg relaxes or becomes fatigued and allows the leg to move, requiring that the leg be readjusted. The movement can cause the leg to pinch or rub nerves or muscle tissue, possibly causing damage.  
      One way to reduce the physical nature of the operation and the number of personnel required to perform the procedure is to use retractors secured to a support that is secured to a surgical table to retract the flesh to expose the surgical site. U.S. Pat. No. 6,315,718 discloses a table mounted retractor system for a method of hip retraction. The table mounted retractor system includes using a table mounted support apparatus to support both flesh retracting retractors to expose the hip joint and bone retracting retractors to dislocate and displace the femural ball from the acetabulum.  
     SUMMARY OF THE INVENTION  
      The present invention includes a method of performing a hip joint surgery on a patient positioned on a surgical table where the hip joint includes a pelvis having an acetabulum, a femur and a femoral ball. The method includes mounting a retractor support to the surgical table. The retractor support is positioned about the hip joint and about an incision into the skin and flesh layers proximate the hip joint. A retractor is positioned within the incision and is manually retracted to retract skin and flesh layers proximate the hip joint. The retractor is secured in a selected position by attaching the retractor to the retractor support. 
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       FIG. 1  is a top view of a surgical support apparatus positioned about a hip joint;  
       FIG. 2  is a top view of a surgical support apparatus retracting a femur from an acetabulum in a pelvis;  
       FIG. 3  is a top view of a surgical support apparatus wherein a prosthetic insert is inserted into the femur in the acetabulum of the pelvis; and  
       FIG. 4  is a perspective view of a clamp having a clamping socket for securing a retractor handle therein. 
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS  
      The present invention relates to a method of performing surgical procedures on or proximate a hip joint. An apparatus used in the surgical procedures of the present invention is generally indicated at  10  in  FIG. 1 .  
      The apparatus  10  includes a retractor support apparatus  12  that is rigidly mounted to a rail  11  of a surgical table  13  in a manner that is well known in the art and is described in U.S. Pat. Nos. 4,617,916, 4,718,151, 4,949,707, 5,400,772, 5,741,210, 6,042,541, 6,264,396 and 6,315,718 all of which are herein incorporated by reference. From the mount to the surgical table  13 , the retractor support apparatus  12  includes left and right support arms  18  and  20  that extend over the surgical table  13 . The support arms  18  and  20  are independently adjustable into an infinite number of selected positions through use of a clamping mechanism  22  which is described in U.S. Pat. Nos. 5,899,627 and 6,264,396, which are herein incorporated by reference. The support arms  18  and  20  extend in a generally lateral or horizontal direction on opposite sides of a hip joint  30 . The clamp  22  secures the adjustable support arms  18  and  20  in selected angular positions with respect to the hip joint  30 .  
      The surgical procedure on the hip joint  30  can be performed with any table mounted support structure and is not limited by the configuration illustrated and described herein. However, the table mounted support structure must provide support for mounting retractors to retract skin, muscle, blood vessels, tendons and bone while providing access to the hip joint  30 .  
      With the table mounted support structure  12  positioned in a selected position about the hip joint  30 , an incision  32  is made through the skin. Typically, the incision is about six to eight inches long but may vary depending upon the surgical procedure being performed.  
      After making the incision  32  through the skin, the surgeon divides the tissue, muscle, blood vessels and nerves to expose the hip joint  30  while causing minimal trauma. To expose the hip joint  30 , a retractor blade  36  of a lateral retractor  34  is positioned within the incision  32 . The tissue, muscle, blood vessels and nerves are laterally retracted from the incision with manual force applied to the lateral retractor  34 . With the lateral retractor  34  in the selected position, a handle  38  of the lateral retractor  34  is positioned within a clamping socket  41  of a clamp  40  positioned on the support arm  18 . The lateral retractor is secured in the selected position by positioning the clamp  40  in the clamping position by rotating a clamping mechanism  43  in the direction of arrows  45 . The clamp  40  having the clamping socket  41  is illustrated in  FIG. 4 .  
      Preferably, the clamping socket  41  allows the retractor handle  38  to be manually forced therein without having to position an end of the handle  38  through the clamping socket  42 , although other clamps, including clamps with clamping bores are within the scope of the present invention. By socket is meant an opening or a cavity into which an inserted part, such as a retractor support apparatus, is designed to fit and wherein the retractor support apparatus can be inserted into the socket from an infinite number of directions in a 180° range starting from a substantially parallel position to a back surface of the socket to a position substantially perpendicular to the back surface and continuing to position again substantially parallel to the back surface of the socket. By lateral is meant a position or direction generally away from the body.  
      A retractor blade  44  of a medial retractor  42  is positioned within the incision  32  generally opposite the lateral retractor  34 . Manual force is applied the medial retractor  42  to retract tissue, muscle, blood vessels and nerves in a medial direction from the hip joint  30 . With the medial retractor  42  in a selected position, a handle  46  of the medial retractor  42  is positioned within a clamping socket  41  of a clamp  40  and the clamp  40  is positioned on the support arm  20 . The clamp  40  is identical to the clamp  40  used to secure the lateral retractor  34  in the selected position. The clamp  40  is secured in the selected position by rotating the clamping mechanism  43  in a direction of arrows  45  as illustrated in  FIG. 4  and thereby positioning the clamp  40  into the clamping position. By medial is meant a position or direction toward the body of the patient.  
      Although two retractors  34 ,  44  are a preferred number of retractors for exposing the surgical site about the hip, more than two retractors supported by the table mounted retractor support apparatus  12  can be utilized to expose the surgical site in the hip while practicing the surgical procedure of the present invention.  
      Mechanical mechanisms (not shown) on retractors may be used to adjust the vertical position of the retractor blade and the lateral or medial position of the retractor blade within the surgical site. Mechanical mechanisms used to adjust the position of the retractor blade include, but are not limited to, articulated joints, rack and pinion systems, racheting mechanisms, wedges, ramps, camming mechanisms and threadable engagements.  
      With the hip joint  30  exposed by the retraction of the skin, tissue, muscle, blood vessels and nerves, the surgical procedure on the hip can be performed. A non-exhaustive list of surgical procedures that can be performed on the hip include repair of a muscle tear, repair of a torn or ruptured tendon or ligament, as well as a hip replacement surgery. The hip replacement surgery includes a complete hip replacement and a partial hip replacement surgery.  
      In a hip replacement surgery, the skin, muscle, blood vessels and nerves are preferably retracted, without having to be severed with a scalpel, to expose the hip joint  30  with at least the lateral and medial retractors. Performing the surgery on the hip joint  30  while minimizing the damage the muscle, blood vessels and nerves minimizes the post-operative pain felt by the patient as well as reducing the time required to rehabilitate the hip joint. However, it is within the scope of the present invention to perform a surgical procedure that requires incising muscles, blood vessels and nerves around the hip joint, if necessary.  
      With the hip joint exposed, the acetabulum  50  within a pelvis  22 , the femoral ball  54  and an upper portion of the femur  56  are viewable through the retracted incision  32 . In preparing the hip joint  30  for the hip replacement surgery, the surgeon has two options in gaining access to the surfaces that accept the inserts. First, the femoral ball  54  may be separated from the femur  56 , typically with a bone saw, while the femoral ball  54  remains within the acetabulum  50 .  
      Referring to  FIG. 2 , the femur  56  is retracted laterally away from the hip joint  30  to gain access to a freshly cut surface  58  on the femur  56  onto which a metal or ceramic femoral insert having a ball  62 . The femur  56  is retracted with a retractor  64  having a blade  66  similar to a Fakuda blade, which is known in the art. The blade includes a generally flat portion  68  and an arcuate end (not shown) that is positioned about the upper portion of the femur  56 . The blade also includes an aperture  70  within both the generally flat portion  68  and the arcuate end (not shown) that aids in gripping the femur  56  and prevents the femur  56  from slipping-along the blade  66 . However, the aperture  70 , while providing additional gripping capability to the retractor blade  66 , is not necessary to retract the. femur  56  away from the acetabulum  50 .  
      The femur  56  is retracted with manual force placed upon the retractor  64 . With the femur  56  manually retracted into a selected position, the retractor  64  is clamped to the support arm  18  by positioning a retractor handle  72  into a clamping socket  42  of a clamp  40  and positioning the clamp  40  into the clamping position. Alternatively, the femur can be retracted with a retractor blade attached to a retractor blade holder supported by the retractor support apparatus  12  where the vertical position is adjusted with an articulated joint and the femur is retracted with a rack and pinion mechanism on the retractor blade holder.  
      The femur  56  is retracted from the acetabulum  50  a selected distance to provide the surgeon access to both a freshly cut surface  58  on the femur  56  and also to the acetabulum  50  having the detached femoral ball  54  retained therein. The detached femoral ball  54  is dislocated from the acetabulum  50  to gain access to the acetabulum  50  for preparation to accept an insert  80 .  
      Alternatively, the femoral ball  54 , while attached to the femur  56 , may be first dislocated from the acetabulum  50  to gain access to the acetabulum  50  for preparation to accept the insert  86 . The femur  56  is laterally retracted, either manually or with a mechanical mechanism as previously disclosed, from the hip joint  30  to gain access to both the femoral ball  54  and the acetabulum  50 . The femoral ball  54  is then separated from the femur  56 , typically with a bone saw, thereby creating the surface  58  to which the insert  60  is secured.  
      The femoral insert  60  that replaces the femoral ball  56  can be shaped to conform to the cut surface  58  of the femur  56  and cemented into place. The insert  60  may also include a single shaft  61  that is positioned within a cooperating cavity  59  in the femur  56 . Alternatively, a plurality of pegs (not shown) extending from the insert  60  are inserted into cooperating cavities (not shown) that are reamed into the femur  56 . The insert  60  is then cemented into place.  
      Alternatively, the insert  60  may include mesh-like surface (not shown) may be positioned onto the femur  56  or within the cavity  59  reamed into the femur  52  such that mesh-like surfaces engage the femur  56  and allows the bone to grow onto the insert  60  to secure the insert  60  to the femur  56 . The femoral insert  60  is preferably constructed of a highly polished metal such as stainless steel or titanium or a ceramic material.  
      After the end of the femur  56  has been prepared to accept the prosthetic insert  60 , the acetabulum  50  is also prepared to accept the second prosthetic insert  80  by reaming a pelvis  52  to a selected configuration similar to the outer surface of the insert  80 . One embodiment of the insert  80  that is positioned within the acetabulum  50  is constructed from a high density polymer, such as polyethylene, which interacts with the polished femoral insert  60  to reconstruct the hip joint  30 . Another embodiment of the insert  80  includes two components, a highly polished metal component (not shown) that is secured to the pelvis  52  having the acetabulum  50  and a polymer component (not shown) that is secured to the metal component (not shown) where the polymer component engages the femoral insert  60 . The metal component (not shown) may include a shaft or a plurality of pegs that engage complimentary cavities that are reamed into the pelvis  52  that includes the acetabulum where the metal component is cemented to the pelvis. Alternatively, the metallic portion insert may include a mesh-like surface that is positioned within the acetabulum where the pelvis grows onto the insert to secure the metallic portion of the insert to the bone.  
      Although either insert  80  is within the scope of the present invention, the two component insert provides an advantage of replacing only the polymeric portion of the insert without having to perform additional surgery on the pelvis in the event the polymeric portion of the insert wears and causes the patient discomfort. With the prosthetic insert  80  secured to the pelvis  52  within the acetabulum  50 , the femoral insert  60  is reducted into the insert  80  within the acetabulum  50  as illustrated in  FIG. 3 .  
      One skilled in the art will recognize that in a total hip-joint replacement surgery, all of the cartilage and synovial membrane attached to or positioned between the pelvis and the femur are removed, which provides the nearly frictionless interaction between the femoral ball and the acetabulum when undamaged. However, the highly polished insert  60  attached to the femur  56  engages the high density polymer insert  80  attached to the pelvis  52  within the acetabulum  50  such that the interaction of the inserts  60 ,  80  is almost frictionless and resembling the function of a healthy hip joint  30 .  
      Although the total hip-joint replacement surgery described first prepares the femur  56  for the femoral insert  60  and then prepares the acetabulum  50  for the pelvic insert  80 , it is within the scope of the present invention to first prepare the acetabulum  50  followed by the femur  56  for accepting prosthetic inserts  80 ,  60 , respectively. Additionally, it is within the scope of the present invention to replace the damaged end of either the femur  56  or the acetabulum  50  in the pelvis  52  with an insert while leaving the undamaged end of the other bone intact.  
      Once the inserts  60 ,  80  have been secured to the femur  56  and within the acetabulum  50  within the pelvis  56 , respectively, the lateral and medial retractors  34 ,  44  are removed from the incision  32  and the incision  32  is sutured closed. A drain (not shown) may be positioned within the hip joint  30  to remove excess blood and fluids that may accumulate in the hip joint  30  caused by the trauma from the total or partial hip joint replacement surgery. Once the hip joint  30  stops draining, the drain is removed and the incision  32  is completely closed.  
      Although the present invention has been described with reference to preferred embodiments, workers skilled in the art will recognize that changes may be made in form and detail without departing from the spirit and scope of the invention.