关节镜外侧半月板下入路技术用于外侧半月板前角层裂下层的切除

目的探讨关节镜外侧半月板下入路切除外侧半月板前角下层的效果。方法 2008年1月～2010年12月,对10例外侧半月板前角层裂采用关节镜外侧半月板下入路切除外侧半月板前角层裂中不稳定的下层。采用3个入路：膝前外侧入路,前内侧入路及外侧半月板下入路。自前内侧入路置入关节镜观察;经前外侧入路使用探沟翻转层裂上层,并尽可能显露下层;经外侧半月板下入路使用直头Punch（篮钳）切除半月板前角层裂的下层。结果无术后并发症。6例术后MRI检查均显示半月板前角下层完全切除。10例随访12～45个月,平均18.9月：9例膝关节完全不痛,1例偶尔运动后疼痛;10例膝关节活动范围均恢复至正常;膝关节Lysholm评分由术前（68.7±12.9）分提高到术后随访时的（94.4±5.7）分（配对t检验,t=7.79,P=0.00）。结论关节镜外侧半月板下入路可安全、有效切除外侧半月板前角层裂中不稳定的下层。     

关节镜下后内侧入路切除胭窝囊肿的临床研究

目的 探讨关节镜下后内侧入路切除腘窝囊肿的手术方法与疗效.方法 2012年1月至2013年3月,采用关节镜下后内侧入路切除腘窝囊肿41例（均为单侧腘窝囊肿）,男17例、女24例,年龄40～55岁.左膝19例、右膝22例,术前均行膝关节MRI检查,来观察膝关节内病变及囊肿与周围组织关系.术中处理膝关节腔内病变后,探查腓肠肌内侧头-半膜肌滑液囊与膝关节腔之间的裂隙样结构并扩大通道或建立双通道,同时刨削切除囊壁,所有操作均在关节镜下操作.本组使用 Rauschning 和 Lindgren标准来评价术后临床效果.结果 术中发现内侧半月板损伤14例、外侧半月板损伤9例、骨关节炎15例（4例合并内侧半月板损伤、3例合并外侧半月板损伤）、关节内游离体5例、髌股关节软骨损伤5例.术中及术后均无感染及重要血管神经损伤,术后随访6～8个月,1例复发.结论 腘窝囊肿并非独立存在,应重视关节内病变的治疗,关节镜下后内侧入路切除腘窝囊肿方法可行,安全可靠,疗效满意.     

膝关节镜下诊治局灶性色素沉着绒毛结节性滑膜炎的临床疗效

目的 探讨采用关节镜技术诊治膝关节局灶性色素沉着绒毛结节性滑膜炎(localized pigmented villonodular synovitis,LPVNS)的临床疗效.方法 2004年6月至2007年9月,关节镜下辅助诊治12例LPVNS患者,男5例,女7例;年龄22～53岁,平均36.3岁.病程最短1个月,最长84个月,平均19.5个月.关节镜下行关节内肿物和局部滑膜切除术,根据膝关节Lysholm评分评估术后疗效.结果 膝关节镜检查发现2例伴内侧半月板前角损伤,1例伴外侧半月板损伤,4例内侧滑膜皱襞增生Ⅲ度,3例髌股关节炎Ⅱ度,其中1例伴内外侧髁软骨Ⅲ度磨损.3例肿物来源于内侧半月板前角附着处滑膜,1例在外侧半月板前角附着处滑膜,3例在髌下脂肪垫,1例在髁间窝,2例在内侧沟,1例在外侧沟.1 例来源于膝关节后纵隔内侧面滑膜.肿物大小平均1.7 cm×1.4 cm×0.8 cm(0.5 cm×0.5 cm×0.5 cm～3 cm×3 cm×2 cm);2例无蒂,10例带蒂,术后组织切片均明确LPVNS的诊断.术后无一例发生膝关节感染.术后随访6～45个月,平均19.9个月.7例无任何不适,3例膝关节下蹲时存在疼痛,1例活动后肿胀,1例行走后疼痛.术后膝关节Lysholm评分为78～100分,平均96.3分;8例优,3例良,1例中.结论 关节镜技术是诊治膝关节LPVNS的一种有效方法 .     

后侧入路关节镜技术在膝关节后间室疾病治疗中的应用

目的探讨后侧入路关节镜技术在膝关节后间室疾病治疗中的手术技巧及疗效。方法回顾性分析自2016-03—2019-03采用膝关节后侧入路关节镜手术治疗的31例膝关节后间室疾病,其中后交叉韧带断裂9例,后交叉韧带胫骨止点撕脱骨折7例,滑膜炎7例,内侧半月板后角撕裂4例,游离体2例,医源性异物1例,肿物1例。结果所有患者均顺利建立后内外侧入路及穿纵隔入路,均清晰显露膝关节后间室所有解剖结构,完成相应疾病的处理。术后切口一期愈合,均未发生感染、骨筋膜室综合征及血管神经损伤等并发症。31例均获得随访,随访时间3个月～3年,膝关节功能恢复满意,色素绒毛结节滑膜炎患者未复发,后交叉韧带重建及后交叉韧带胫骨止点撕脱骨折复位固定患者膝关节恢复稳定性,膝关节屈伸功能恢复良好。结论联合应用后内外侧入路及穿纵隔入路关节镜手术治疗膝关节后间室疾病创伤小,操作方便,病灶清除彻底,能够取得满意效果。     

关节镜下滑膜全切术治疗膝关节慢性滑膜炎

[目的]探讨关节镜下膝关节滑膜全切术的手术方法及临床疗效.[方法]自2007年6月～2010年8月,收治各种原因导致的膝关节反复积液的患者共32例,男18例,女14例;年龄12 ～64岁,平均36.5岁,病程3个月～5年,平均8.4个月.膝关节慢性感染8例,类风湿性关节炎10例,色素沉着绒毛结节性滑膜炎8例,膝关节滑膜结核3例,不明原因3例.所有患者行关节镜下膝关节滑膜全切术,在常规前内、前外入路的基础上,结合后内侧、后外侧及髌上外侧入路,6例色素沉着绒毛结节性滑膜炎患者采用跨后纵隔入路.术后配合相应的药物治疗.[结果]所有患者均获得随访,随访时间24 ～ 46个月,平均30.5个月.2例色素沉着绒毛结节性滑膜炎患者手术24个月后膝关节肿胀复发,余患者关节肿胀消退,浮髌试验阴性.末次随访时膝关节屈曲由术前的(36.25 ±7.93)°增加到术后(120.00±13.20)°,Lysholm评分由术前的(34.84 ±7.04)分提高到术后(85.00±5.75)分,优良率87.50％.[结论]通过关节镜技术能彻底切除膝关节滑膜,创伤小,能最大程度的恢复膝关节功能.     

膝关节镜治疗老年人盘状半月板损伤

目的探讨膝关节镜治疗老年人盘状半月板损伤的疗效。方法对19例外侧盘状半月板损伤的老年患者进行关节镜手术,依具体损伤情况采用半月板成形术15例,次全切除术2例,全切除术2例。同时对伴随的骨关节炎、关节游离体、内侧半月板损伤、滑膜皱襞增生给予切除增生滑膜、关节软骨修整、游离体取出及内侧损伤半月板次全切除。结果18例获得随访,时间6～24（15±9）个月,按Ikeuchi膝关节评分标准：优13例,良2例,可2例,差1例。结论膝关节镜下治疗老年人盘状半月板损伤可以获得良好的效果。     

关节镜下治疗后交叉韧带胫骨附着部撕脱骨折

目的探讨后交叉韧带(PCL)胫骨附着部撕脱骨折在关节镜下复位、固定的方法。方法2000年8月～2003年7月,12例PCL胫骨附着部撕脱骨折患者在关节镜下复位、固定,手术采用后内侧和后外侧入路,打开PCL后侧膈膜,观察全部后关节腔结构。术中使用我们自行设计的滑臂式导向器定位,用0.7mm钢丝固定。采用Lysholm评分方法评定膝关节功能及患者运动水平。结果12例患者获12～38个月随访。X线片示所有患者撕脱骨折获得骨性愈合,无膝关节活动受限。后抽屉试验检查无后侧不稳定。术前Lysholm评分平均61分(48～74分),术后12个月平均94分(92～100分)。无窝部神经、血管损伤并发症。结论关节镜下复位、钢丝固定PCL胫骨附着部撕脱骨折固定牢稳,能早期康复训练,术后疗效良好。但关节镜下操作有一定难度。     

关节镜下经后入路保留残留后交叉韧带纤维和板股韧带重建后交叉韧带

目的探讨关节镜下经后入路保留残留后交叉韧带(PCL)纤维和板股韧带重建PCL的临床应用效果。方法对9例患者应用自体腘绳肌腱在关节镜下结合常规入路和后入路保留残留的PCL纤维和板股韧带重建PCL。胫骨隧道定位在PCL胫骨止点外侧关节面下方1～1.5 cm处。股骨隧道经前外侧入路定位于股骨内侧髁关节软骨后方1 cm处。自体肌腱移植物两端用可吸收界面螺钉固定。术后6个月了解膝关节功能恢复情况。结果 9例均随访6个月。患者无伸膝受限;2例10°～15°屈膝受限,1例Ⅰ度后抽屉试验阳性。Ly-sholm膝关节功能评分和IKDC评分较术前均有显著改善(P<0.01)。结论膝关节后入路保留PCL残留纤维和板股韧带重建PCL,镜下视野清楚、无盲区,操作安全,韧带的胫骨止点定位准确,同时符合生物学和生物力学,短期疗效肯定。     

膝后腓肠肌内侧入路修复后交叉韧带胫骨撕脱骨折

目的 探讨膝后腓肠肌内侧入路修复膝关节后交叉韧带(PCL)胫骨撕脱骨折。方法 应用膝后腓肠肌内侧入路对11例PCL胫骨撕脱骨折行复位固定。结果 膝后腓肠肌内侧入路对修复PCL胫骨撕脱骨折。解剖层次清晰，出血量极少，不需要切断和重新缝合组织，并发症少，简便、安全、快捷、实用。结论 膝后腓肠肌内侧入路非常适于修复PCL胫骨撕脱骨折，同时也适于股骨内侧滑车后部、胫骨平台后内侧骨折复位内固定。     

关节镜下经膝半月板滑膜缘入路治疗半月板囊肿24例

目的探讨关节镜下经膝半月板滑膜缘入路行半月板囊肿切除术的效果。方法对24例膝关节半月板囊肿患者（均合并半月板损伤,其中2例合并前叉韧带断裂）在关节镜下经半月板滑膜缘入路进行囊肿切除术,同时修复半月板损伤。结果 23例患者获得随访,时间26-50个月。MRI检查均未发现囊肿复发;按国际膝关节评分委员会（IKDC）膝关节功能评分,术前为（67.2±4.1）分,末次随访时为（89.6±5.7）分。结论关节镜下经半月板滑膜缘入路能够完成膝关节半月板囊肿的彻底切除,并能够最大程度地保留半月板,手术效果好。     

Posterior trans-septal portal for arthroscopic surgery of the knee joint

Summary: The authors introduce a safe arthroscopic technique of making a portal through the posterior septum of the knee joint, posterior to the posterior cruciate ligament (PCL). This posterior trans-septal portal makes it possible for the arthroscope or the working instruments inserted through the posteromedial portal to reach the posterolateral compartment. With this portal, complete arthroscopic visualization of the posterior compartment and easier arthroscopic procedures for the posterior compartment of the knee joints are possible, including the posterior and posterosuperior aspect of the both femoral condyles, the posterior horns of both menisci, the posterior and inferior portion of the PCL, the posterior meniscofemoral ligament, the posterior septum, and the posterior capsule. We have used this technique in more than 150 knees for arthroscopic total synovectomy for arthritis of various origins, arthroscopic PCL reconstructions, arthroscopic removal of encapsulated loose bodies or tumors located behind the PCL, arthroscopic repairs of tears in the posterior horns of the medial menisci using the all-inside technique, arthroscopic pullout suture fixation of the avulsion fracture of tibial attachment of PCL, and others. No complications such as injuries of the popliteal neurovascular structures have occurred in our experience.Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 7 (October), 2000: pp 774–779     

A new arthroscopic technique for revision of the posterior compartment in symptomatic total knee arthroplasty

Arthroscopy is effective in treating the symptomatic knee following total knee arthroplasty. A small number of patients complain about postoperative pain in the posterior compartment. Loose bodies and degenerated remnants of the menisci are the main reasons for this pain. We present a new technique for diagnostic and therapeutic arthroscopy of the posterior compartments in patients with symptomatic total knee arthroplasty. After standard anterior arthroscopy, a wide circular notchplasty is performed to allow easy access to the posterior lateral compartment of the knee joint and to apply a posterolateral working portal under direct arthroscopic control. If inspection of the posteromedial compartment is necessary, the loose tissue behind the posterior cruciate ligament is resected to gain access to the posteromedial compartment.     

膝关节镜下膝后侧腔室联合手术入路的探讨

[目的]探讨在关节镜下膝关节后侧腔室联合手术入路的重要性和可操作性。[方法]经过前内侧、前外侧和股骨髁切迹以及后内侧、后外侧和后纵隔内切口联合入路分别入镜、入器械，进行膝关节后侧腔室的探查和手术操作。[结果]216例（239膝）应用联合入路探查和治疗，其中5例膝因关节僵硬操作失败；175例膝用于治疗后侧腔室疾病，膝关节后侧腔室手术视野显著改善，探查和手术操作完善，均达到手术目的。1例膝内侧隐神经不全损伤，没有腘后神经、腓总神经、腘后血管、交叉韧带等重要组织损伤。[结论]膝关节后侧腔室病变较多，是检查和治疗的重要部位，并非“技术盲区”。这种联合手术入路，手术风险低，具备可操作性，可以提高手术效率和质量，可作为膝关节镜下常规手术入路。     

Arthroscopic excision of the ganglion in the posterior septum by posterior trans-septal portal: report of two cases

We report two cases of ganglion cysts in the posterior septum of the knee joint, one as parameniscal cyst from the posterior horn of the lateral meniscus extending to posterior septum, and the other as a cyst located in the posterior septum adjacent to the posterior cruciate ligament, which were both arthroscopically excised expediently by posterior trans-septal portal. The posterior compartment of the knee is not readily accessible by ordinary arthroscopic portals, and therefore has been considered as ‘blind spot’ conventionally. The posterior trans-septal portal is useful for assorted diagnostic or manipulative procedures in the posterior compartment of the knee.     

Proximity of the popliteal artery to the PCL during simulated knee arthroscopy: implications for establishing the posterior trans-septal portal

This study defines the sagittal distance from the posterior cruciate ligament (PCL) to the popliteal artery under simulated arthroscopic conditions. This information is relevant for posterior knee arthroscopy, particularly for the safe establishment of the posterior trans-septal portal. Measurements from the PCL to the popliteal artery were made on sagittal magnetic resonance images obtained in a previous study of 10 fresh-frozen cadaveric knees. The mean sagittal distance from the mid-PCL to the popliteal artery was 29.1 +/- 11 mm (range: 18-55 mm). The mean sagittal distance from the proximal PCL fovea to the popliteal artery was 9.7 +/- 5 mm (range: 3-16 mm). The results of this study provide the arthroscopist working in the posterior compartments of the knee with a more detailed knowledge of the anatomic relationship between the PCL and popliteal artery. This knowledge will help minimize the risk of iatrogenic vascular injury during arthroscopic knee surgery.     

A new guide system for posteromedial portal in arthroscopic knee surgery

A view through the posteromedial portal is necessary to observe the posterior portion of the knee joint such as the tibial attachment of the posterior cruciate ligament (PCL) or the posterior horn of the medial meniscus, which is barely, visible through anterior portals. Especially in arthroscopic PCL reconstruction, the arthroscopic view through the posteromedial portal is indispensable for boring a tibial bone tunnel that is correctly sited. However, it is difficult to create this portal safely without cartilaginous or meniscal damage. We have produced new guidelines to facilitate the process of creating the posteromedial portal even by inexperienced hands. With a cannulated K-wire and a cannulated rod with sharp teeth, the joint capsule of the posteromedial corner can be penetrated safely with or without viewing the posteromedial corner through the anterolateral portal. Based on our experience of using this guide system, we believe it will be a great help to many orthopaedic surgeons in performing various types of arthroscopic surgery, not only for PCL reconstruction but also for arthroscopic synovectomy. Received: 21 August 1997     

Arthroscopic posterior cruciate ligament reconstruction using the posterior trans-septal portal

We describe an arthroscopic technique for the reconstruction of the posterior cruciate ligament (PCL), while preserving the remnant bundle of the original PCL and meniscofemoral ligament, using the posterior trans-septal portal. The posterior trans-septal portal provides an excellent visualization of the PCL tibial attachment and an easy access to the tibial tunnel without injuring any neurovascular structure. The remnant bundle of the original PCL and meniscofemoral ligament, which significantly contributes to the posterior stability of the knee joint, are preserved to be healed with a graft and subsequently form an integrated structure. We report a new arthroscopic technique for an effective reconstruction of the PCL, using the posterior trans-septal portal.     

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.     

Posterior “back and forth” approach in arthroscopic surgery on the posterior knee compartments

We report the feasibility, indications, and usefulness of an arthroscopic approach to the posterior knee compartments. We developed an arthroscopic approach to the posterior knee compartment involving use of a posteromedial portal and a posterolateral portal opposite each other. Each posterior portal is used in alternation for the arthroscope and instruments. The posterior portals are established using an original “back and forth” technique. The feasibility of the technique was evaluated on a cadaver. It allowed us to define safety rules to protect the vessels and nerves that course through the popliteal fossa. The approach provided a broader field of view compared with classical techniques. After removal of the septum dividing the posterior compartment, the synovial fold enclosing the posterior cruciate ligament and lining the upper and posterior parts of the posterior capsule was readily accessed, suggesting that this approach may be particularly valuable for total synovectomy. This was confirmed in 6 patients with villonodular synovitis, in whom the new approach was used in combination with arthroscopic anterior synovectomy. This technique allows removal of parts of the synovium that are difficult to access through conventional arthroscopic approaches. For total synovectomy, it can be used as an alternative to open posterior synovectomy, in combination with arthroscopic anterior synovectomy.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 3 (March), 2003: pp 321–325     

Loose body as an obstacle for posterolateral arthroscopic portal formation in the knee joint

In this report, we present a case with difficult arthroscopic posterolateral portal formation due to loose body located in posterior compartment. These loose bodies are responsible for pain, decreased range of motion and cartilage damage in the knee joint. By making the posterior trans-septal portal prior, posterolateral portal could be made without difficulty completing the planned arthroscopic procedure.