关节镜下打结技术.ppt

Zhijiexi,MD,ArthroscopicknottypingainstructionManual,TheDepartmentofTraumaandHandSurgeryTheFirstAffiliatedHospitalofuniversityofGuangxiTraditionalChineseMedicine,AnincreasingnumberofsurgeonsareperformingarthroscopicsurgeryinthekneetorepairmeniscaltearsandintheshouldertorepairrotatorcufforlabraltearsManyarealsoperformingcapsularshiftstotreatinstability.Essentialtotheseproceduresistheabilitytotiearthroscopicknotstoapproximateintraarticular,Introduction,ThesurgeonmustsequentiallyconstructtheknotoutsidethejointandthenpasstheknotintothejointthroughsmallcannulasTyingarthroscopicknotsistechnicallydemandingandrequiresconsiderablepracticeWiththepopularityofarthroscopicsurgery,thenumberofusedarthroscopicknotsandthenumberofsurgeonsusingtheseknotshasincreased,KnotTyingPrinciples,ThegoalofknottyingistoapproximatetissueundertensionandmaintainthetissueinappositionuntilbiologicrepairandhealingcanoccurItisimperativeforallsurgeonstolearnanduseknot-tyingtechniquesthatminimizethechanceofknotfailure,Knotsecurityfriction,internalinterference,andslackbetweenthrowsFrictionisinherenttothesuturematerialInternalinterferencetheconfigurationoftheknotandincreasedbythelengthofthecontactbetweenthelooplimbandthepostlimbslackbetweentheindividualthrowsineachknottomaximizeloopsecurityslippagecanleadtofailureoftissueapposition,KnotTyingPrinciples,fourdifferentprocessesofknotfailureknotslippageandlooseningsuturebreakagetissuefailuresutureanchorpulloutfrombonethroughsuturebreakage,Knotfailure,KnotTerminology,postlimb(alsocommonlyknownastheaxiallimb)looplimb(alsocommonlyknownasthewrappinglimb,workingend,runningend,orfreeend)Knotsareconstructedbytyingthelooplimbaroundthepostlimb(Fig.1),FIGURE1.Loopandpostconfiguration,ArthroscopicKnotPushers,Anarthroscopicknotpusherisadeviceusedtoadvancetheloopdownthepostlimbintothejointtocreatetheknot.,Arthrexknotpushers.A.Single-hole,B.Double-hole,C.6thFinger,FIGURE3.Mitekknotpushers.A.Single-hole,B.Double-hole,C.Slotted,double-holeknotpushersanddoublediameterknot,double-holeknotpushersanddoublediameterknotpushersliketheArthrex6thFinger(Arthrex,Naples,FL).Double-diameterknotpushersprovidebetterloopsecuritycomparedtostandardsingle-holeknotpushers,Double-holeknotpusher,FIGURE4.Double-holeknotpusher.,HowtoUsetheDouble-DiameterKnotPusher,FIGURE5.A-F.TyingknotswiththeArthrex6thfinger,SutureProperties,Twotypesofsuturesarecommonlyusedintyingarthroscopicknots:apermanent,braided,polyester,nonabsorbablesutureandanabsorbable,monofilamentsutureExamplesofpermanent,braided,polyester,nonabsorbablesuturesareEthibondandTicronExamplesofabsorbable,monofilamentsuturesarePDSII,polydiaxononeandMaxon,polyglyconate,Braidedpolyesterhasincreasedpliability,ductility,ahighercoefficientoffrictionandgreaterstrengththandoesabsorbablemonofilamentBecausethebraidedsutureismorepliable,thevolumeoftheknotisdecreasedandtheseknotscanbecinchedtighter.KnotstiedwithEthibondwereshowntobestrongerwhencomparedtoPDSIIinseveralbiomechanicalstudiesHowever,braidedpolyestermayfraywithexcessivehandling,whichmayleadtosuturerupture,Braidedpolyestersuturemaybecoatedto:improvesurgeonhandlingreducefrictionbetweenthesutureandsurroundingtissue,whichcanleadthetissuedamagedecreasefrictionbetweensuturelimbs,whichmayleadtofrayingHowever,suturecoatingdecreasesthecoefficientoffrictionoftheknot,whichtheoreticallyincreasestheriskofknotslippage,Knotstiedwithabsorbable,monofilamentsuturesareeasiertoslidedownapostanddonotfrayThereislessfrictionbetweenthesutureandsurroundingtissueleadingtolesspotentialtissuedamagewhenthesutureispulledthroughthetissueabsorbablesuturesdissolveanddonotleaveknotsthatmaycauseapersistentinflammatoryreactionaftertissuehealingAbsorbablesuturescanapposetissueunderstressforapproximatelysixweekswithcompleteabsorptionoccurringinapproximatelysixmonths,However,absorbablemonofilamentsuturesarehardertohandlethanpolyestermakingitmoredifficulttokeepknotstightandsecureAlso,aabsorbablemonofilamentsuturewillfailearlierwithcyclicloadingthanpolyestersutureandmayexpandbyplasticdeformationmorethan30%ofitslengthbeforebreaking,ThesizeofthesutureisalsoafactorindeterminingaknotsholdingcapacityandalsothetensilestrengthofthesutureitselfClinicalfailureofallknotsandsuturetypesimprovedby100%whensuturesizewasincreasedby2gaugesUSP(U.S.Pharmacopeia.ThesizesuturemostcommonlyusedinarthroscopicsurgeryisNo.1orNo.2.,KnotTypes,Thereareavarietyofknotincludenonslidingknots,slidingknots,andlockingknots.Nonslidingknotsareknotsthatdonotslidethoughthetissuesbeingapposed.TheyincludethesquareknotandknotsconsistingofaseriesofhalfhitchesliketheRevoknot(34)Althoughthesquareknotfailsathigherloadsthandoseriesofhalfhitchesinhand-tiedknots(38),thesquareknotisnotcommonlyusedarthroscopically.,Thesquareknotisaflatknotinwhichbothstrandsenterandleavetheknotparalleltoeachother(Fig.6).Inordertotieasquareknot,symmetrictensionmustbesimultaneouslyappliedtoeachlimb,whichisdifficulttodoarthroscopicallyIfasymmetrictensionisappliedtooneofthelimbs,theknotconvertstotwononidenticalhalfhitchesThus,mostarthroscopicsurgeonspreferusingaseriesofhalfhitches,FIGURE6.Squareknotconfiguration.,Slidingknots,liketheDuncanloop(27),areusefulinopposingtissueundertension.Whiletyingaslidingknot,thepoststrandisheldundertensionwhiletheloopstrandistiedaroundit.Becausethepoststrandisnotincorporatedintothestructureoftheknot,theknot,oncetied,caneasilymovedownthepostresultinginaslidingknotinsteadofaflatknotsuchasthesquareknot.Oncetheslidingknotsareseated,theyareoftenlockedwithaseriesofhalfhitches.Someslidingknotspreferentiallyslideinonlyonedirection,AlockingknotisamodificationofaslidingknotAsimpleslidingknotcanloosenbeforeaseriesofhalfhitchesarethrownto“lock”theslidingknotinplacelockingknots(alsoknownasflipknots)havebeendevelopedtomaintaininitialloopsecuritythatdoesnotloosenwhentensionisremovedThepoststrand“flips,”convertingtheloopstrandintothenewpoststrandandlockingtheknotintoplace.AnexampleofalockingknotistheSMCknot.lockingknotsdonotneedtobesupplementedwithaseriesofhalfhitchesTheauthorsofthismanualhavefoundlockingknotswithoutreinforcinghalfhitchestobeinferiorintensilestrengthtoknotsreinforcedwiththreereversedhalfhitchesonalternatingposts(unpublisheddata),Lockingandslidingknotscanbeadvancedintothejointjustbypullingonthepost.Thiscancausetensionattherepairsite,whichcandamagethetissuebeingapposed.Tensionattherepairsitecanbeminimizedbypushingtheknotaheadwiththeknotpusherwhilesimultaneouslypullingonthepostlimb.Withlockingandslidingknots,itisimportantthatthelooplimbisatleasttwiceaslongasthepostlimb.Ifitisnot,whenpullingthepostlimbtoadvancetheknotthroughthecannulaandintothejoint,theshortenedlooplimbmaybepulledintothecannulamakingitimpossibletosecuretheknot.Whenusingaslidingorlockingknotconfiguration,itisimportanttoensurethatthesutureslideseasilythroughthetissuebeingopposed.Ifthesuturedoesnotslideeasily,thesurgeonshouldconsiderusinganonslidingknot.,KnotPushingandPulling,Knotconfigurationscanbeeitherpushedorpulledintothejoint.hearthroscopicknot-tyingdeviceispositionedonthelooplimbandisadvancedpastthehalfhitchthuspullingtheloopoverthepostlimbintothejoint(Fig.7A).Thearthroscopicknot-tyingdeviceispositionedonthepostlimbbehindtheknotthuspushingtheloopoverthepostlimbintothejoint(Fig.7B).,FIGURE7.A.Knotpulling,B.Knotpushing.,TyingHalfHitches,Usingtheonehandknot-tyingtechnique,halfhitchescanbetiedeitherunderhandoroverhandThefollowinginstructionsdefineanunderhandloopandanoverhandloop,FIGURE8.A-E.Underhandhalfhitch.,ConfigurationofHalfHitches,Halfhitchescanbethrowninthesamedirection(twosuccessiveoverhandhitches)orcanbethrowninoppositedirections(anoverhandhitchfollowedbyanunderhandhitch)Halfhitchescanalsobetiedonoppositeposts.TeraandAberg(37)developedanomenclaturefordescribingflatknots.,PostSwitching,FIGURE13.A.Parallelloopandpostlimbs.B.Parallelloopandpostlimbswitha“flat”knot.,FIGURE14.A.Twistedloopandpostlimbs.B.Whentyingaknotwithtwistedpostandlooplimbs,theknotdoesnotlie“flat.”C.Thefinalknotconfigurationwilllooseniftheknotistiedwhentheloopandpostlimbsaretwisted.,ChanandBurkhartdescribedamayincreasethespeedoftheknot-tyingprocessandalsohelplimittwistingofthesuturelimbs.Onecan“flip”ahalfhitchbyreleasingtensiononthepostlimbandpullingonthelooplimb.Whenthepostisswitched,thedirectionofthehalfhitchisalsoreversed.Theauthorsofthistechniquereportthatitiseasiertofliphalfhitchesusingmonofilamentbecauseitmorereadilyconvertstoaflatknot,butitcanalsobedonewithbraidedsuture.,Holdthepostinthenondominanthandandtheloopinthedominanthand(Fig.15A).Movetheoriginalpostforwardandaheadofthehalfhitch.Applyparalleltractiononthepostandloopsimultaneouslyconvertingthehalfhitchtoaflatknot(Fig.15B).Applyaxialtractiontothelooplimbconvertingitintothenewpostlimbandthehalfhitchisreversed(Fig.15C).,PostSwitchingTechnique,FIGURE15.A-C.Postswitchingtechnique,ArthroscopicKnot-TyingTechniques,Itisimportanttodetermineifthesutureslidesthroughthetissueandsutureanchorpriortoknottying.Ifthesuturedoesnotreadilyslide,aslidingorlockingknotshouldnotbeusedandanonslidingknotshouldbechosenOnlyonepairofsuturesshouldbewithintheworkingcannuladuringarthroscopicknottying.Ifmorethanonepairofsuturesarewithintheworkingcannuladuringtying,thereisahighlikelihoodthatthesutureswillbecometwistedandknottyingwillbecomequitetediousifnotimpossible.Additionalsuturesshouldbeshuttledviaamonofilamentsuture(lesstissueabrasion)orbyanarthroscopicgraspertoanaccessoryportalTransparentcannulasarerecommendedforarthroscopicknottying.Thesecannulasallowthesurgeontoseeifthereisanytwistingofthesuturestrandspriortoknottying,ThearthroscopicsurgeonshouldensurethatthereisnoredundantsofttissuearoundthetissuebeingapposedorinthepathofthesuturelimbsbecausethiswillimpedeknottyingandincreasethelikelihoodofknotfailureWhentyinghalfhitcheswithastandardsingle-holeknotpusher,thefirstthrowcommonlyslipswhentheknotpusherisremovedinpreparationforthesecondthrowWhenthesecondthrowisadvanced,thereisachancethatthehitcheswilllockpriortocompleteappositionofthetissueTopreventthis,thesurgeoncanthrowthefirsttwohitchesinthesamedirectionallowingthehitchestoslidedowntheposttoapposethetissueAnothermethodofpreventinginitiallooplooseningistouseadouble-diameterknot-pushingdevice,suchastheArthrex6thtomaintaintensionontheinitialhitchwhilethrowingthesecondhitch,Non-SlidingKnots,FIGURE16.A-F.Squareknot.,RevoKnot,TheRevoknotisaseriesofmultiplehalfhitchesmadebyalternatingthepostanddirectionofthehalfhitches.TherehavebeenseveralmodificationstotheRevoknot,FIGURE17.A-H.OriginalRevoknot.,TheOriginalRevoknotconsistsoftworeversedhalfhitchesonanidenticalpostfollowedbypostswitchingandtworeversedhalfhitches.Throwanoverhandlooparoundthepost(Fig.17A).Pulltheloopintothejointwiththeknotpusheronthelooplimb(Fig.17B)Withdrawtheknotpusherwhilemaintainingtensiononthepostlimb.Throwanunderhandlooparoundthesamepost(Fig.17C)Pulltheloopintothejointandseattheknotwiththeknotpusher.Oncethetwohitchesareseated,past-pointtocinchtheknotdown(Fig.17D).Switchpostsandthrowanunderhandlooparoundthenewpost(Fig.17E).Pulltheloopintothejoint,seattheknotwiththeknotpusher,andpast-pointtocinchtheknotdown(Fig.17F).Next,throwanoverhandlooparoundthepost(Fig.17G).Pulltheloopintothejoint,seattheknotwiththeknotpusher,andpast-pointtocinchtheknotdown.(Fig.17H),SnydersKnot,SnydersKnot,SnydersisanothervariationoftheRevoknotThrowanoverhandlooparoundthepost(Fig.18A).Pulltheloopintothejointwiththeknotpusheronthelooplimb(Fig.18B)Withdrawtheknotpusherwhilemaintainingtensiononthepostlimb.Throwanunderhandlooparoundthesamepost(Fig.18C)Pulltheloopintothejointandseattheknotwiththeknotpusher.Oncethetwohitchesareseated,past-pointtocinchtheknotdown(Fig.18D).Switchpostsandthrowanoverhandlooparoundthenewpost(Fig.18E).Pulltheloopintothejoint,seattheknotwiththeknotpusher,andpast-pointtocinchtheknotdown(Fig.18F).Next,throwanunderhandlooparoundthepost(Fig.18G).Pulltheloopintothejoint,seattheknotwiththeknotpusher,andpast-pointtocinchtheknotdown(Fig.18H).Switchpostsandthrowanoverhandlooparoundthenewpost(Fig.18I).Pulltheloopintothejoint,seattheknotwiththeknotpusher,andpastpointtocinchtheknotdown(Fig.18J).,FIGURE19.A-K.Revoknot.,ThecurrentRevoknotisamodificationoftheOriginalRevoknotThrowanunderhandlooparoundthepost(Fig.19A).Advancetheloopwiththeknotpusheronthelooplimbuntilthefirsthalfhitchisseated(Fig.19B).Withdrawtheknotpusherwhilemaintainingtensiononthepostlimb.Throwanotherunderhandlooparoundthesamepost(Fig.19C).Pulltheloopintothejointandseattheknotwiththeknotpusher.Oncethetwohitchesareseated,past-pointtocinchtheknotdown(Figs.19D,E).Throwanoverhandhalfhitcharoundthepostandadvancewiththeknotpusher(Fig.19F).Furthertensionbypastpointingandapplytensiononbothlimbswhileholdingthe(Fig.19G).Switchpostsandthrowanunderhandlooparoundthenewpost(Fig.19H).Pulltheloopintothejoint,seattheknotwiththeknotpusher,andpastpointtocinchtheknotdown(Fig.19I).Switchpostsandthrowanoverhandlooparoundthenewpost(Fig.19J).Pulltheloopintothejoint,seattheknotwiththeknotpusher,andpastpointtocinchtheknotdown(Fig.19K).,SlidingKnots,OverhandThrow,DuncanLoop,TheDuncanloopwasoriginallydescribedinthefishingliterature(Uni-Knot)andhasbeenmodifiedforuseinarthroscopicsurgery.ThearthroscopicDuncanloopisalsoknownastheFishermansknotortheHangmansknotThedifferencebetweenthefishingknotandthearthroscopicknotisthedirectiontheloopstrandtravelsaroundthepost.WhentyingthefishingDuncanloop,onewrapsthelooplimbaroundthepostinadirectionawayfromthejoint.TotiethemodifiedDuncanlooporHangmansknot,thesurgeonsequentiallywrapsthelooplimbaroundthepostinadirectiontowardthejoint,FIGURE21.A-F.FishingDuncanloop.,BerkleyDuncanLoopKnot,ArthroscopicDuncanLoop(HangmansKnot)(Fig.22),FIGURE22.A-F.ArthroscopicDuncanloop.,Frenchknot.FIGURE23.A-H.,FIGURE23.A-H.Frenchknot.,TheFrenchknot(22)isaslidingknotthatisamodificationoftheDuncanloop.Makethepostlimbhalfaslongasthelooplimb.Graspthesuturesbetweenthethumbandindexfingerofyournon-dominanthand(Fig.23A).Createasmallcircleintheloopstrandbypassingtheloopoverthecombinedpostandloopstrandsandholditbetweenyourthumbandindexfinger(Fig.23B).Makeatotaloffourloopsaroundboththepostandthelooplimbstravelingtowardthejoint(Fig.23C).Passthetailoftheloopstrandoverandthroughthesmallcircleintheloopstrandthatisheldbetweenthethumbandindexfinger(Fig.23D).Passthetailoftheloopstrandunderandthroughtheloopcirclecreatedbythedistalendoftheloopstrandandthecombinedlimbsoftheloopandpoststrands(Fig.23E).Pullonboththelooplimbandthepostlimbsymmetricallytotightentheknot(Fig.23F).Advancetheknotbypullingonthepostlimbwhilepushingtheknotdownwiththeknotpusheronthepoststrand(Fig.23G).Locktheknotwithaseriesofthreealternatinghalfhitcheswithpostswitching(Fig.23H).Throwanunderhandloopontheoriginalpost.Tensionwiththeknotpusher.Switchposts.Throwanoverhandloopoverthenewpost.Tensionwiththeknotpusher.Switchposts.Throwanunderhandloopontheoriginalpostagain.Tensionwiththeknotpusher.TheFrenchknotwasshowntohaveahigherloadtofailurewhencomparedtotheDuncanloopandtheRevoknot,RoederKnot,TheRoederknotisaslidingknotthatisavariationoftheDuncanloop.ItwasoriginallyusedintonsillectomysurgeryanddescribedintheGermanliteraturebyRderin1918Therehavebeenseveralmodificationsoftheknotthathavebeendescribedsincetheinitialdescriptionoftheknot.ModificationsoftheRoederknotarecurrentlyusedinbothlaparoscopicandarthroscopicsurgery,FIGURE24.A-G.Roederknot.,Thepostlimbshouldbeonehalfthelengthofthelooplimb.Throwthefirstlooparoundthepostlimbandthenholdtheloopandposttogetherwiththethumbandindexfingerofthenon-dominanthand(Fig.24A).Throwasecondlooparoundboththepostandlooplimbs(Fig.24B).Throwathirdlooparoundonlythepostlimbandbetweenthepostandloop(Fig.24C).Passthetailoftheloopbetweenthesecondandthirdturnsandinbetweenthelooplimbandthepostlimb(Fig.24D).Tensiontheknotbygentlypullingonboththepostandthelooplimbssimultaneously(Fig.24E).Whilepullingonthepostlimb,pushtheknotintothejointwiththeknotpusheronthepoststrand(Fig.24F).Locktheknotwithaseriesofthreealternatinghalfhitcheswithpostswitching(Fig.24G).Throwanunderhandloopontheoriginalpost.Tensionwiththeknotpusher.Switchposts.Throwanoverhandloopoverthenewpost.Tensionwiththeknotpusher.Switchposts.Throwanunderhandloopontheoriginalpostagain.Tensionwiththeknotpusher.TheRoederknotwasshowntobeinferiortotheDuncanloopandtheSnyderknotinloadtoclinicalfailuretrialsbutastatisticalsignificancewasnotfound(26).,Savoie-ModifiedRoederKnot(Fig.25),TheSavoie-ModifiedRoederknotisalockingknotinsteadofaslipknotThepostlimbshouldbeonehalfthelengthofthelooplimb.Throwanunderhandlooparoundthepoststrand(Fig.25A).Throwasecondlooparoundboththepostandlooplimbs.Besuretoleaveasmall“hole”inthelooppriortothrowingthesecondloop(Fig.25B).Throwathirdlooparoundboththepostandlooplimbs(Fig.25C).Throwafourthlooparoundboththepostandlooplimbs(Fig.25D).Wrapthelooplimbaroundonlythepostandbringitawayfromthejoint(Fig.25E).Passthetailofthelooplimbbetweenthe“hole”madeinstepC(Fig.25F).Looselytensiontheknotbutdonotpullontheloopstrandorthiswillprematurelylocktheknot(Fig.25G).Whilepullingonthepostlimb,pushtheknotintothejointwiththeknotpusheronthepoststrand.Whentheknotisseated,pushdownontheknotpushertoholdtheknotinplaceandwhilemaintainingtensiononthepoststrand,pullontheloopstrandtolocktheknot.Thiswillpreventtheknotfromlooseningoncetensionisreleasedfromthestrands(Fig.25H).Locktheknotwithaseriesofthreealternatinghalfhitcheswithpostswitching(Fig.25I）,Lieurance-ModifiedRoederKnot(Fig.26),FIGURE26.A-H.Lieurance-ModifiedRoederknot.,TheLieurance-ModifiedRoederknotisalockingknotinsteadofaslipknotThepostlimbshouldbeonehalfthelengthofthelooplimb.Throwanoverhandlooparoundonlythepoststrand(Fig.26A).Throwasecondloopacrossboththepostandlooplimbs(Fig.26B).Throwathirdloopacrossboththepostandlooplimbs(Fig.26C).Wrapthelooplimbaroundthepostonlyandbringitbetweenthepostandlooplimbs(Fig.26D).Passthetailofthelooplimboverandthroughtheinitialloopmadebythepostandlooplimbs(Fig.26E).Looselytensiontheknotbutdonotpullontheloopstrandorthiswillprematurelylocktheknot(Fig.26F).Whilepullingonthepostlimb,pushtheknotintothejointwiththeknotpusheronthepoststrand.Whentheknotisseated,pushdownontheknotpushertoholdtheknotinplaceandwhilemaintainingtensi