醫(yī)學ppt--腘窩囊腫的關節(jié)鏡治療

1、Arthroscopic Treatment of Popliteal Cyst（腘窩囊腫的關節(jié)鏡治療）,------浙江省運動醫(yī)學中心浙江省人民醫(yī)院運動醫(yī)學及關節(jié)外科 顧海峰,一、概述,早在1840年已經被Adams所認識,Baker在1877年以他的名字命名為貝克囊腫(Baker囊腫) 。腘窩囊腫是腘窩滑液囊腫的總稱，多發(fā)生于半膜肌與腓腸肌,并常與關節(jié)腔相通。臨床表現(xiàn)為關節(jié)疼痛及活動受限。分為原發(fā)性和繼發(fā)性兩種。,二、發(fā)

2、病機制,單向流通的“閥門機制”（只進不出）。存在半膜肌與腓腸肌內側頭滑液囊( GSB) 。關節(jié)積液增多引起關節(jié)囊內壓增高, 通過平股骨髁腓腸肌內側頭處的橫向裂隙樣結構進入GSB, 但不能從GSB流向關節(jié)腔,導致囊腫的形成和持續(xù)存在。關節(jié)內疾病(半月板損傷、軟骨退變、交叉韌帶損傷、滑膜炎等)在腘窩囊腫的發(fā)病過程中起重要作用。Sansone等認為半月板尤其是內側半月板損傷是致病的關鍵, 84%-90%的患者可見有內側半月板損傷。,三

3、、臨床表現(xiàn),Rauschning和Lndgren對腘窩囊腫評價分級如表1：,四、診斷,癥狀及體征。MRI、B超。B超將腘窩囊腫分為3型：（1）單純囊腫型：囊腫孤立存在于腘窩軟組織間,與深部關節(jié)腔不相通, 其形態(tài)呈圓形或橢圓形,囊壁較薄,邊界光滑清楚,包膜完整,透聲好。（2）分葉囊腫型：此型基底部與關節(jié)腔相通, 有寬窄不一的蒂部管狀結構,囊腫形態(tài)欠規(guī)則呈多樣性, 囊壁厚薄不均, 可見粗細不一的光帶及散在點狀回聲, 探頭加壓囊腫

4、形態(tài)改變。（3）囊液混濁型：囊腫呈單房或分葉狀,囊壁毛糙增厚,內見密集光點回聲或粗斑點狀回聲,呈懸浮狀,可飄動,下垂部位可見回聲分層,此型可見于囊內出血或感染。,五、治療,原則：有癥狀才處理。開放手術、關節(jié)鏡手術。開放手術：疤痕大，影響關節(jié)功能、易損傷血管神經、易復發(fā)。（在囊腫切除時要同時將關節(jié)囊縫合）關節(jié)鏡手術：微創(chuàng)、恢復快、關節(jié)功能影響小，復發(fā)率低。,六、關節(jié)鏡手術的方法,方法一：,成功治療的關鍵是膝關節(jié)內相關病損的處理和重

5、建滑囊與關節(jié)腔正常的雙向流通,囊腫本身不應是外科治療的主要目標!,方法二：,FIGURE 1. (A) Schematic cross-section image of the knee with the opening of the connection. The image shows the location of the posteromedial portal and the anterolateral viewing por

6、tal. (P, popliteal cyst.) (B) Arthroscopic finding from the anterolateral portal of the right knee shows a connecting hole (curved arrow) at the posteromedial compartment that verifies the retraction of the capsular fold

7、 (C) by probing (straight arrow). (M, medial femoral condyle.),FIGURE 2. (A) Arthroscopic finding from the anterolateral portal of the right knee shows that the capsular fold (C) was resected by basket forceps (arrow) in

8、serted from the posteromedial portal. (B) Arthroscopic finding from the anterolateral portal of the right knee shows a yellowish cystic fluid that gushes out to the posteromedialcompartment by compressing the posteromed

9、ial part skin of the ballooned cyst. (M, medial femoral condyle.),FIGURE 3. Arthroscopic finding of the anterolateral portal of theright knee shows an opening (curved arrow). The opening is shownat the posteromedial si

10、de of the medial head of the gastrocnemius(G) after the capsular fold was completely resected with a shaver(straight arrow) and basket forceps. (M, medial femoral condyle.),FIGURE 4. (A) Schematic cross-sectional image

11、 of the knee with theopening of the connection. The image shows the location of theposteromedial viewing portal (b). (P, popliteal cyst.) (B) Arthroscopicfinding from the posteromedial portal of the right knee showss

12、eptation and loose fragments of the inside of the popliteal cyst.,FIGURE 5. (A) Schematic cross-sectional image of the knee with the opening of the connection. The image shows the location of the posteromedial viewing po

13、rtal (b) and the posteromedial cystic portal (c). (P, popliteal cyst.) (B) Gross view of the right knee joint that was positioned for arthroscopic surgery for a popliteal cyst. The arthroscope was inserted through the po

14、steromedial portal, anda motorized shaver was introduced from the posteromedial cystic portal. (C) Arthroscopic finding from the posteromedial portal of the right knee shows that a motorized shaver (S) was inserted to t

15、he inside of the popliteal cyst through the posteromedial portal. The cyst wall (W) was resected with the shaver.,FIGURE 6. (A) A preoperative MR image (axial view) shows a huge popliteal cyst with multiple septation. (B