腘窝囊肿的关节镜治疗

ArthroscopicTreatmentofPoplitealCyst

（腘窝囊肿的关节镜治疗）------浙江省运动医学中心浙江省人民医院运动医学及关节外科顾海峰当前第1页\共有20页\编于星期五\12点一、概述早在1840年已经被Adams所认识,Baker在1877年以他的名字命名为贝克囊肿(Baker囊肿)。腘窝囊肿是腘窝滑液囊肿的总称，多发生于半膜肌与腓肠肌,并常与关节腔相通。临床表现为关节疼痛及活动受限。分为原发性和继发性两种。当前第2页\共有20页\编于星期五\12点二、发病机制单向流通的“阀门机制”（只进不出）。存在半膜肌与腓肠肌内侧头滑液囊(GSB)。关节积液增多引起关节囊内压增高,通过平股骨髁腓肠肌内侧头处的横向裂隙样结构进入GSB,但不能从GSB流向关节腔,导致囊肿的形成和持续存在。关节内疾病(半月板损伤、软骨退变、交叉韧带损伤、滑膜炎等)在腘窝囊肿的发病过程中起重要作用。Sansone等认为半月板尤其是内侧半月板损伤是致病的关键,84%-90%的患者可见有内侧半月板损伤。当前第3页\共有20页\编于星期五\12点三、临床表现Rauschning和Lndgren对腘窝囊肿评价分级如表1：当前第4页\共有20页\编于星期五\12点四、诊断症状及体征。MRI、B超。B超将腘窝囊肿分为3型：（1）单纯囊肿型：囊肿孤立存在于腘窝软组织间,与深部关节腔不相通,其形态呈圆形或椭圆形,囊壁较薄,边界光滑清楚,包膜完整,透声好。（2）分叶囊肿型：此型基底部与关节腔相通,有宽窄不一的蒂部管状结构,囊肿形态欠规则呈多样性,囊壁厚薄不均,可见粗细不一的光带及散在点状回声,探头加压囊肿形态改变。（3）囊液混浊型：囊肿呈单房或分叶状,囊壁毛糙增厚,内见密集光点回声或粗斑点状回声,呈悬浮状,可飘动,下垂部位可见回声分层,此型可见于囊内出血或感染。当前第5页\共有20页\编于星期五\12点五、治疗原则：有症状才处理。开放手术、关节镜手术。开放手术：疤痕大，影响关节功能、易损伤血管神经、易复发。（在囊肿切除时要同时将关节囊缝合）关节镜手术：微创、恢复快、关节功能影响小，复发率低。当前第6页\共有20页\编于星期五\12点六、关节镜手术的方法当前第7页\共有20页\编于星期五\12点方法一：成功治疗的关键是膝关节内相关病损的处理和重建滑囊与关节腔正常的双向流通,囊肿本身不应是外科治疗的主要目标!当前第8页\共有20页\编于星期五\12点当前第9页\共有20页\编于星期五\12点方法二：FIGURE1.(A)Schematiccross-sectionimageofthekneewiththeopeningoftheconnection.Theimageshowsthelocationoftheposteromedialportalandtheanterolateralviewingportal.(P,poplitealcyst.)(B)Arthroscopicfindingfromtheanterolateralportaloftherightkneeshowsaconnectinghole(curvedarrow)attheposteromedialcompartmentthatverifiestheretractionofthecapsularfold(C)byprobing(straightarrow).(M,medialfemoralcondyle.)当前第10页\共有20页\编于星期五\12点FIGURE2.(A)Arthroscopicfindingfromtheanterolateralportaloftherightkneeshowsthatthecapsularfold(C)wasresectedbybasketforceps(arrow)insertedfromtheposteromedialportal.(B)Arthroscopicfindingfromtheanterolateralportaloftherightkneeshowsayellowishcysticfluidthatgushesouttotheposteromedialcompartmentbycompressingtheposteromedialpartskinoftheballoonedcyst.(M,medialfemoralcondyle.)当前第11页\共有20页\编于星期五\12点FIGURE3.Arthroscopicfindingoftheanterolateralportaloftherightkneeshowsanopening(curvedarrow).Theopeningisshownattheposteromedialsideofthemedialheadofthegastrocnemius(G)afterthecapsularfoldwascompletelyresectedwithashaver(straightarrow)andbasketforceps.(M,medialfemoralcondyle.)当前第12页\共有20页\编于星期五\12点FIGURE4.(A)Schematiccross-sectionalimageofthekneewiththeopeningoftheconnection.Theimageshowsthelocationoftheposteromedialviewingportal(b).(P,poplitealcyst.)(B)Arthroscopicfindingfromtheposteromedialportaloftherightkneeshowsseptationandloosefragmentsoftheinsideofthepoplitealcyst.当前第13页\共有20页\编于星期五\12点FIGURE5.(A)Schematiccross-sectionalimageofthekneewiththeopeningoftheconnection.Theimageshowsthelocationoftheposteromedialviewingportal(b)andtheposteromedialcysticportal(c).(P,poplitealcyst.)(B)Grossviewoftherightkneejointthatwaspositionedforarthroscopicsurgeryforapoplitealcyst.Thearthroscopewasinsertedthroughtheposteromedialportal,andamotorizedshaverwasintroducedfromtheposteromedialcysticportal.(C)Arthroscopicfindingfromtheposteromedialportaloftherightkneeshowsthatamotorizedshaver(S)wasinsertedtotheinsideofthepoplitealcystthroughtheposteromedialportal.Thecystwall(W)wasresectedwiththeshaver.当前第14页\共有20页\编于星期五\12点当前第15页\共有20页\编于星期五\12点FIGURE6.(A)ApreoperativeMRimage(axialview)showsahugepoplitealcystwithmultipleseptation.(B)Afollow-up(postoperative9months)MRimage(axialview)showsthatthepo