跨膝关节后纵隔入路的建立及临床应用

目的 探讨跨膝关节后纵隔入路（ATS）的建立方法及临床应用效果。方法 10具新鲜防腐膝关节标本进行后纵隔的大体解剖,65例行后室关节镜镜下观察,包括类风湿关节炎、色素绒毛结节性滑膜炎、骨性关节炎、后室游离体或异物、后交叉韧带（PCL）损伤或撕脱骨折、半月板后角损伤、不明原因关节肿痛积液、剥脱性骨软骨炎、化脓性关节炎、痛风。2002年1月—2005年6月,我们共采用ATS入路进行关节镜检查和治疗22例。先建立前外侧入路,关节镜监视下建立后外侧入路。同法建立前内侧与后内侧入路。把关节镜置于后内侧入路,从前内侧入路进入刨刀逐步刨除PCL表面的滑膜组织,再把关节镜置于前内侧入路,从后内侧入路引入钝头转换棒,指向PCL后缘中份处的后纵隔,向外侧轻柔地推顶后纵隔。把关节镜置于后外侧入路,镜视下引导穿出钝头转换棒建立ATS。结果后纵隔位于膝关节后室正中,在矢状面上呈幕布状,在横断面上呈三明治样结构。关节镜下见后纵隔表面被覆盖滑膜组织。22例均成功建立ATS入路,占同期膝关节后室治疗的34％（22／65）。行膝关节后室滑膜切除术7例,游离体取出6例,PCL重建术4例,PCL撕脱骨折复位固定2例。骨性关节炎6例中,分别行镜下软骨成形、炎性滑膜切除、半月板成形术。所有病例均未发生血管神经损伤。所有病例临床随访4～45个月,平均20个月,9例患者仍有轻微疼痛或关节肿胀,2例患者疼痛剧烈,已推荐行全膝关节置换术,其余11例患者未见关节肿痛症状复发。结论 ATS入路在镜下视野无盲区,能够跨后纵隔进行手术操作,是一种安全有效诊治膝关节后室疾病的方法。从内侧向外侧建立ATS比较可靠,后交叉韧带可以作为建立ATS时的内标志物。     

Lateral meniscus and lateral femoral condyle cartilage injury by retained cement after medial unicondylar knee arthroplasty

The authors experienced an unusual case of a patient with a complex tear of the lateral meniscus and adjacent lateral femoral condyle cartilage injury in the contralateral compartment by retained cement, possibly located at the posteromedial side of the medial tibial component after unicondylar knee arthroplasty. Arthroscopic partial meniscectomy and cartilage microfracture were successfully performed. Two small cement fragments were removed from the posterolateral compartment. A sharp pain in the lateral side disappeared postoperatively and posterior knee pain was much reduced.     

Arthroscopy of total knee arthroplasties: Indications and technical problems

Summary   Background: Postoperative complaints after total knee arthroplasty range from restriction in range of motion, recurrent swelling, and soft tissue impingement through to prosthesis failure with no obvious radiological abnormality. This study looks at the indications and technical problems of arthroscopy in the treatment of symptomatic total knee arthroplasty. Methods: Fourteen arthroscopies were performed between 3 days and 10 years following total knee arthroplasty. Six of these cases presented significantly decreased range of motion, four had proximal medial joint line pain, two had pain with no obvious cause, one had a suspected patella incongruence with metal-back contact, and one case had a postoperative haemarthrosis. Results: Arthroscopy revealed adhesions and intra-articular fibrous bands resulting in incongruence of the patellofemoral joint and decreased range of motion. Medial compartment pain was due to pseudomeniscal hypertrophic villous synovium. In one case, the pain was due to chronic infection and open synovectomy was undertaken. A fracture of the polyethylene inlet was found by arthroscopy in one case. The suspected patella malalignment with metal-back contact was confirmed by arthroscopy. Technical problems encompassed mirror images, the possibility of damaging the components by arthroscopic manipulation, and the variants of prosthesis. Conclusions: Arthroscopy of total knee arthroplasties is a good minimally invasive method for the diagnosis and treatment of postoperative dysfunction, such as arthrofibrosis, soft tissue impingement, patella instability, infection, breakdown of implants and haemarthrosis.      

Invited commentary to: ‘Arthroscopy of total knee arthroplasties: Indications and technical problems’ (Eur Surg 2002;34:309–311)

Summary   Background: Postoperative complaints after total knee arthroplasty range from restriction in range of motion, recurrent swelling, and soft tissue impingement through to prosthesis failure with no obvious radiological abnormality. This study looks at the indications and technical problems of arthroscopy in the treatment of symptomatic total knee arthroplasty. Methods: Fourteen arthroscopies were performed between 3 days and 10 years following total knee arthroplasty. Six of these cases presented significantly decreased range of motion, four had proximal medial joint line pain, two had pain with no obvious cause, one had a suspected patella incongruence with metal-back contact, and one case had a postoperative haemarthrosis. Results: Arthroscopy revealed adhesions and intra-articular fibrous bands resulting in incongruence of the patellofemoral joint and decreased range of motion. Medial compartment pain was due to pseudomeniscal hypertrophic villous synovium. In one case, the pain was due to chronic infection and open synovectomy was undertaken. A fracture of the polyethylene inlet was found by arthroscopy in one case. The suspected patella malalignment with metal-back contact was confirmed by arthroscopy. Technical problems encompassed mirror images, the possibility of damaging the components by arthroscopic manipulation, and the variants of prosthesis. Conclusions: Arthroscopy of total knee arthroplasties is a good minimally invasive method for the diagnosis and treatment of postoperative dysfunction, such as arthrofibrosis, soft tissue impingement, patella instability, infection, breakdown of implants and haemarthrosis.     

Pseudomeniscus following total knee arthroplasty as a cause of persistent knee pain

Persistent pain following total knee arthroplasty is an uncommon complication that may have any of several causes. In the case reported here, a patient who had undergone total knee arthroplasty developed a symptomatic pseudomeniscus that was successfully treated by arthroscopic debridement. Histopathologic analysis of the pseudomeniscus revealed a unique fibrocartilaginous structure, which may give insight into its pathogenesis. Symptomatic pseudomeniscus is one of several postoperative complications of total knee arthroplasty for which arthroscopy may be indicated.     

Screw migration from total knee prostheses requiring subsequent surgery

Complications in total knee arthroplasty directly related to hardware failure other than polyethylene wear are rare. We report 2 cases of symptomatic screw migration into the joint space from total knee prostheses. In the first case, a screw disengaged from a constrained condylar knee prosthesis. Arthroscopy using standard arthroscopy portals and a small arthrotomy were performed to remove the screw. In the second case, symptomatic screw disengagement and posterior migration from the tibial component of a posterior-stabilized prosthesis occurred. Revision with replacement of the polyethylene insert and locking screw was required.     

The posteromedial portal in knee arthroscopy: An analysis of diagnostic and surgical utility

We reviewed 400 consecutive knee arthroscopy cases in a predominantly sports medicine practice to determine (1) the frequency of posteromedial portal usage under a prospectively established set of indications, and (2) the impact of posteromedial portal access on patient diagnosis and management. Diagnostic posteromedial portals were used in 22% of anterior cruciate ligament (ACL)-deficient knees, and in 11% of stable knees with nonpatellar (usually meniscal) lesions. When used, posteromedial portal visualization showed treatable lesions 64% of the time, the majority of which were repairable peripheral meniscus tears. In 63% of these cases, no definite lesion had been identified by initial routine anterior portal viewing and probing. Of the 22 patients with posteromedial meniscus tears that were discovered only via posteromedial portal access, 9 had recently undergone anterior portal arthroscopy by other surgeons, during which none of these tears were detected. Posteromedial surgical portals (19 cases) were most useful for synovectomy, posterior cruciate stump resection before arthroscopic reconstruction, and posterior horn medial meniscectomy in exceptionally tight knees. Posteromedial portal access is often useful diagnostically in cases where (1) posteromedial meniscal lesions are frequent (i.e., ACL-deficient knees) and/or suspected on the basis of preoperative symptoms or imaging studies, and (2) full, direct visualization of the entire superior meniscosynovial junction is not possible via standard anterior portals. The option of a surgical posteromedial portal should be entertained whenever frontal approaches for posteromedial instrument work prove inefficient or unsuccessful.     

Arthroscopic approach to the posterior compartment of the knee using a posterior transseptal portal

Arthroscopic surgery of the posterior compartment of the knee is difficult when only two anterior portals are used for access because of the inaccessibility of the back of the knee. Since its introduction, the posterior transseptal portal has been widely employed to access lesions in the posterior compartment. However, special care should be taken to avoid neurovascular injuries around the posteromedial, posterolateral, and transseptal portals. Most importantly, popliteal vessel injury should be avoided when creating and using the transseptal portal during surgery. Purpose of the present study is to describe how to avoid the neurovascular injuries during establishing the posterior three portals and to introduce our safer technique to create the transseptal portal. To date, we have performed arthroscopic surgeries via the transseptal portal in the posterior compartments of 161 knees and have not encountered nerve or vascular injury. In our procedure, the posterior septum is perforated with a 1.5-3.0-mm Kirschner wire that is protected by a sheath inserted from the posterolateral portal and monitored from the posteromedial portal to avoid popliteal vessel injury.     

Double Posteromedial Portals for Posterior Ankle Arthroscopy in Supine Position

Both posterior and anterior arthroscopy of the ankle may be indicated in the same patient. With the patient supine, it is possible to reach most intraarticular structures of the ankle through the standard anterior portals, but difficult to examine the posterior compartments and to perform hindfoot endoscopy. In most patients following the anterior procedure the patient is positioned prone to operate on the posterior compartment. We describe a two-portal posteromedial hindfoot procedure that allows the surgeon to reach both the posterior joint space and the extraarticular compartment of the hindfoot with the scope and instruments, regardless of diagnosis, with the patient supine. After arthroscopy on the anterior portion of the foot using standard anterior portals, the two posteromedial portals allow endoscopic inspection and management of abnormalities in this region without repositioning the patient and without any remarkable local complication.     

Anterior vs Posterior Periarticular Multimodal Drug Injections: A Randomized,Controlled Trial in Simultaneous Bilateral Total Knee Arthroplasty

Background

Currently, various techniques are used to overcome postoperative pain after total knee arthroplasty. A local analgesic infiltration with periarticular multimodal drug injection (PMDI) is favorable because of its simplicity, safety, and efficacy. The present study compared the efficacy of a PMDI at the anterior vs posterior compartments.

Debridement arthroscopy. 10-year followup.

The treatment of osteoarthritis of the knee is a difficult problem. In the senior author's opinion, nonaggressive arthroscopic debridement of the knee is an effective procedure to relieve pain and restore function in patients with osteoarthritis of the knee. A subjective telephone interview of patients done 10 or more years after arthroscopic debridement evaluated the long term results of this treatment in patients with osteoarthritis of the knee. The patients all were candidates for total knee replacement who selected arthroscopy as a temporizing procedure. Of the 191 knees in patients undergoing arthroscopic debridement, 77 patients (91 knees) were contacted for followup. Sixty-seven percent of the 91 knees did not have total knee arthroplasty at an average of 13.2 years followup. The Tegner activity score averaged 3.5 and patient satisfaction averaged 8.6 on a 0 to 10 scale. Twenty-one patients (30 knees) or (33%) had total knee arthroplasty at an average of 6.7 years. Seven of these had total knee arthroplasty within 2 years of arthroscopic debridement. Six of these seven knees had Outerbridge Grade 4 articular cartilage changes and clinically significant meniscus tears. Seven of the 19 knees (37%) with Outerbridge Grade 4 changes in 80% of one knee compartment did not require total knee arthroplasty after greater than 10 year followup. The difficulties in long term followup in this patient population is evident, yet the number of patients who had a functional lifestyle after arthroscopic debridement was notable.     

Silent compartment syndrome complicating total knee arthroplasty: continuous epidural anesthesia masked the pain

Posterior dislocation is an uncommon complication of total knee arthroplasty (TKA) using a posterior stabilized total knee prosthesis, and it usually results from flexion instability. Acute posterior dislocation of a posterior stabilized prosthesis complicated by compartment syndrome of the leg has not previously been reported in the literature. We report a 62-year-old woman with posterior dislocation of her posterior stabilized TKA when her knee was in extension. It was further complicated by compartment syndrome with severe muscle necrosis. The diagnosis of compartment syndrome was delayed, partly because of continuous epidural anesthesia that completely abolished the pain and partly because of the low index of suspicion, as compartment syndrome is not well recognized as a possible complication of TKA. This case report strongly emphasizes that continuous epidural anesthesia is contraindicated in the case of complicated TKA because important clinical cues to neurovascular complications could be masked.     

Prior Knee Arthroscopy Increases the Failure Rate of Subsequent Unicompartmental Knee Arthroplasty

BackgroundIn selected patients, knee arthroscopy is performed prior to unicompartmental knee arthroplasty (UKA) to treat symptomatic mechanical pathology, delay arthroplasty, and assess the knee compartments. The purpose of this study was to determine if knee arthroscopy prior to UKA is associated with increased rates of UKA failure or conversion to total knee arthroplasty (TKA).MethodsData was collected from the Humana insurance database from 2007-2017. Patients who underwent knee arthroscopy within two years prior to UKA were identified and matched with controls based on age, gender, Charlson Comorbidity Index, smoking status, and obesity. Rates of conversion to TKA and failure for various causes were compared between cohorts.ResultsPrior to propensity matching, 8353 UKA patients met inclusion criteria. Of these, 1079 patients (12.9%) underwent knee arthroscopy within two years of UKA and were matched to 1079 patients (controls) who did not undergo knee arthroscopy in the two years preceding UKA. No differences in demographics/comorbidities existed among cohorts. Compared to controls, the knee arthroscopy cohort was more likely to experience failure for aseptic loosening (2.4% vs 1.1%; OR 2.166; P = .044) and significantly more likely to require conversion to TKA (10.4% vs 4.9%; OR 2.113; P < .001) within two years of UKA.ConclusionKnee arthroscopy within two years of UKA is associated with an increased rate of UKA conversion to TKA and a higher rate of UKA failure from aseptic loosening. Although clinicians should be mindful of this association when performing knee arthroscopy in patients who may be indicated for future UKA, further research is needed to better characterize these findings.     

Endogenous cortisol production in response to knee arthroscopy and total knee arthroplasty

BACKGROUND: There is controversy about whether patients who take exogenous glucocorticoids, such as prednisone, require supplemental (exogenous) glucocorticoids in order to meet the physiological demands of surgery. In this study, we sought to define the magnitude of the surgical stress response in normal patients undergoing major and minor elective orthopaedic surgery. METHODS: A prospective, observational study of thirty patients who had not taken exogenous glucocorticoids and who underwent either elective knee arthroscopy or elective unilateral total knee arthroplasty was performed. Regional anesthesia was used for all patients, and all patients treated with total knee arthroplasty had continuous epidural anesthesia for forty-eight hours after the surgery. The stress response was assessed on the basis of serum and twenty-four-hour urine cortisol levels; comparisons of the urine values were made after correcting for renal function by calculating the cortisol-to-creatinine clearance ratio. RESULTS: Preoperatively, patients undergoing arthroscopy and total knee arthroplasty had similar cortisol-to-creatinine clearance ratios. Patients treated with total knee arthroplasty had a significant (p < 0.001) surgical stress response on the day of the surgery, compared with baseline, whereas patients treated with arthroscopy did not. The mean cortisol-to-creatinine clearance ratio in patients treated with total knee arthroplasty was highest on the day of the surgery and decreased on the third postoperative day. However, on the third postoperative day, the cortisol-to-creatinine clearance ratio still was significantly higher than the baseline value (p < 0.001). Significant differences in the serum cortisol levels also were detected between the patients treated with arthroscopy and those treated with total knee replacement. CONCLUSIONS: Patients undergoing total knee arthroplasty had a significant surgical stress response (a seventeenfold increase in the cortisol-to-creatinine clearance ratio); patients treated with arthroscopy did not. Additional studies, including a prospective trial of patients taking exogenous glucocorticoids, are warranted. Until they are performed, the significantly increased cortisol production observed in non-steroid-dependent patients following total knee arthroplasty leaves open the possibility that steroid-dependent patients undergoing this procedure could benefit from perioperative glucocorticoid supplementation. Since the non-steroid-dependent patients in the present series did not mount a substantial stress response to knee arthroscopy, our results do not support the use of supplemental steroids for that less-invasive procedure.     

Isolated Resurfacing of the Previously Unresurfaced Patella Total Knee Arthroplasty

Postoperative anterior knee pain can be challenging after primary total knee arthroplasty. Isolated patellar resurfacing may provide symptomatic improvement in those patients with an unresurfaced patella. Seventeen isolated patellar resurfacing procedures were performed. Patient outcomes were evaluated using the Knee Society clinical and roentgenographic evaluation systems. Continued symptomatology and overall patient satisfaction were also analyzed. No revisions have been necessary at 47 months of follow-up. Overall, Knee Society knee scores and knee function scores significantly improved. Eight patients (53%) are asymptomatic and were satisfied with the procedure, whereas 7 patients (47%) continue to have anterior knee pain and are unsatisfied. Isolated patellar resurfacing for anterior knee pain in total knee arthroplasty with an unresurfaced patella has a low morbidity and revision rate but may not provide patients with predictable symptomatic improvement.     

Synovial entrapment: a complication of posterior stabilized total knee arthroplasty

BACKGROUND: We observed a complication of posterior stabilized total knee arthroplasty involving hypertrophy of tissue proximal to the patella associated with pain during active knee extension from 90 degrees of flexion. The purpose of this paper was to describe synovial entrapment and to determine if design features of the prosthesis predispose patients to the complication. METHODS: Between April 1990 and June 1999, we performed 459 consecutive posterior stabilized primary total knee arthroplasties using three prosthetic designs with different femoral intercondylar geometries. We identified twenty-six patients (twenty-seven knees) in whom arthroscopic débridement of the knee or open arthrotomy with débridement of the knee had been subsequently performed because of a diagnosis of synovial entrapment. We reviewed the records of these patients to identify the knee components that had been used and the symptoms and conditions that necessitated additional treatment. RESULTS: Symptoms (grating, crepitation, and pain with active knee extension from 90 degrees) necessitating subsequent débridement occurred in 13.5% (nineteen) of 141 knees treated with the Anatomic Modular Knee-Congruency implant, 3.8% (eight) of 212 treated with the Anatomic Modular Knee-Posterior Stabilized implant, and none of the 106 treated with the Press Fit Condylar Sigma-Posterior Stabilized implant. All patients had difficulty rising from a chair and climbing stairs; however, none had symptoms when standing or walking. No patient had a patellar clunk. The symptoms occurred at a mean of seven months after the arthroplasty in the patients with an Anatomic Modular Knee-Congruency implant and at a mean of twenty months after the arthroplasty in those with an Anatomic Modular Knee-Posterior Stabilized implant. Débridement of the frond-like hypertrophic synovial tissue at the distal aspect of the quadriceps tendon alleviated symptoms in all patients. No nodules were identified during the arthroscopy. CONCLUSIONS: Synovial entrapment is characterized by hypertrophic synovial tissue at the superior pole of the patella. Use of a posterior stabilized femoral component with a proximally positioned or wide femoral box is more likely to result in this complication.     

关节镜辅助单髁置换术治疗膝内侧间室骨性关节炎的临床疗效观察

目的总结关节镜辅助单髁置换术治疗膝内侧间室骨性关节炎的临床疗效。方法选择自2008-03—2011-01行手术治疗的18例单侧膝关节骨性关节炎。均以膝关节内侧间室病损为主。术前进行MR及X线片评估;术中采用关节镜进行检查和清理。并行膝关节内侧间室单髁置换术：术后进行膝关节功能及影像学评估。结果所有患者均获平均21（18～36）个月随访,影像学检查显示假体位置良好,无松动与假体周围骨溶解的迹象。末次随访时膝关节功能HSS评分由术前71．3分提高至87．2分,优15膝,良3膝;平均关节活动范围（ROM）127°（112～141°）。结论关节镜下准确评估、清理关节病损为人工膝关节单髁置换术提供临床依据,提高了疗效,是治疗膝关节单间室骨性关节炎的有效方法。     

Patellar Reconstruction Using Posterior Femoral Condyle: A 5-Year Follow-Up

A patient with rheumatoid arthritis presented to clinic with an increasingly painful knee. The patient had undergone patellectomy for patellofemoral arthritis 10 years previously. After knee arthroscopy showing extensive arthritic changes, it was decided to offer primary arthroplasty of the knee with patellar reconstruction using posterior lateral femoral condyle graft taken at the time of arthroplasty. The positive outcome from this case is encouraging and constitutes a further option in patients with prior patellectomy undergoing knee arthroplasty.     

Outcomes After Arthroscopic Evaluation of Patients With Painful Medial Unicompartmental Knee Arthroplasty

Background

Persistent pain after medial unicompartmental knee arthroplasty (UKA) is a prevailing reason for revision to total knee arthroplasty (TKA). Many of these pathologies can be addressed arthroscopically. The purpose of this study is to examine the outcomes of patients who undergo an arthroscopy for any reason after medial UKA.

Ankle anatomy for the arthroscopist. Part I: The portals

Proper portal placement is critical to performing good diagnostic and therapeutic arthroscopy. When the portals are positioned improperly, visualization can be impaired, making diagnosis and treatment more difficult. Three main anterior portals are available in arthroscopy of the ankle: anteromedial, anterolateral, and anterocentral. Posterior portals are also routinely used in ankle arthroscopy and can be established at a posterolateral or posteromedial position or directly through the Achilles tendon. Because of the potential for serious complications, the anterocentral and transAchilles portals are no longer used. Other portals have been described to obtain more complete access, particularly to the posterior compartment of the ankle joint. This work reviews the relationships that exist between the most important anatomic structures and arthroscopic portals of the ankle.