不同体位下肘关节镜常用入路与周围神经的解剖关系

目的 比较不同体位下各种肘关节镜入路与毗邻神经血管的解剖关系,评价肘关节镜操作中各种标准入路的安全性及应用价值.方法 选用新鲜尸体肘关节10个进行解剖,测量9种标准肘关节镜入路与毗邻神经血管的最近距离,并根据各入路下关节镜检的镜下视野及操作灵活性评价其应用价值. 结果肘关节镜人路与毗邻神经距离受注水膨胀关节、肘关节伸直或屈曲及前臂旋前或旋后体位变化影响.肘关节屈曲90°前臂旋后、中立、旋前位,前外侧入路关节镜套管与桡神经距离分别为(2.9±1.1)mm、(4.5±1.5)mm、(5.8 ±1.7)mm,穿刺造成神经损伤风险大;肘关节伸直前臂旋后位2例肘关节中套管与桡神经直接接触.近端前内侧或近端前外侧人路观察肘关节前间室、后正中人路观察后间室视野良好且穿刺风险小.后方入路均安全. 结论近端前内侧或近端前外侧入路优于前内侧或前外侧人路,与后正中入路结合应用可基本满足多数肘关节镜手术的要求,是一组安全、有效的人路点.     

Anatomical study of the ankle with view to the anterior arthroscopic portals

This article evaluates the risk of interference with the neurovascular structures in the four anterior ankle arthroscopic portals, described on each side of the extensor tendons: anteromedial, medial midline, anterocentral and anterolateral. Complications after ankle arthroscopies have been described in up to 17%, most being neurovascular. To quantify the neurovascular risks we dissected 68 cadaveric feet and evaluated the correlations between tendons, vessels and nerves. The mean distance between tibialis anterior and extensor hallucis longus and between extensor hallucis longus and extensor digitorum longus is 4 mm, but in 10-20% these tendons are in apposition or are overlapped. The tibialis anterior vascular bundle was absent in 11.8%, was located between the tibialis anterior and the extensor hallucis longus in 3% and between the extensor hallucis longus and the extensor digitorum longus in 64.7%. A peroneal vascular bundle or branches of the tibialis anterior vascular bundle were located lateral to the extensor digitorum longus/peroneus tertius tendon in 88.2%. Transverse vascular branches were identified in 41.2% over the medial side of the joint line and in 52.9% over the lateral side. The deep peroneal nerve was located between the extensor hallucis longus and the extensor digitorum longus tendons in 58.8%. The superficial peroneal nerve had branches located between the tibialis anterior and the extensor hallucis longus tendons in 2.9%, between the extensor hallucis longus and the extensor digitorum longus tendons in 23.5% and lateral to the extensor digitorum longus/peroneus tertius tendon in 32.4%. These results show that the anteromedial and medial midline portals are the safest. The anterolateral portal should be noted not only for the risks to the superficial peroneal nerve, but also to the peroneal vessels.     

Three-Portal Technique for Anterior Cruciate Ligament Reconstruction: Use of a Central Medial Portal

Standard endoscopic reconstruction of the anterior cruciate ligament (ACL) is performed with the use of 2 arthroscopic portals. The surgical error most commonly associated with ACL reconstruction is improper positioning of the tunnel. Errors in femoral tunnel position may be related to poor visualization of the lateral wall. When anatomic double-bundle ACL reconstruction is performed, proper visualization of the lateral wall is essential to ensure correct placement of both tunnels. We propose the use of a central portal, in addition to more standard anterolateral and anteromedial portals, to enhance visualization of the lateral wall. In addition, the arthroscope can be moved interchangeably throughout the portals during the procedure for improved viewing during specific steps. An accessory anteromedial portal placed inferiorly and medially allows placement of the femoral tunnels while providing a high central anteromedial portal for best visualization of the lateral wall. As a result, no notchplasty is required, and a more anatomic reconstruction can be performed.     

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.     

Arthroscopic anatomy of the lateral elbow: A comparison of three portals

Ten fresh cadaveric elbows were used to evaluate the proximity of the radial nerve and its branches to three anterolateral portals. A proximal anterolateral portal used routinely at our institution and located 2 cm proximal and 1 cm anterior to the lateral epicondyle was compared with the distal anterolateral portal described by Andrews and with a mid-anterolateral portal. The three portals were initially established without joint distention while the elbows were flexed 90°. Measurements were then obtained with and without joint distention at flexion angles of 0° and 90°. The radial nerve was found to be an average distance of 3.8 mm at extension and 7.2 mm at 90° of flexion from the distal anterolateral portal, located 3 cm distal and 1 cm anterior to the lateral epicondyle. Conversely, the distance between the proximal anterolateral portal cannula and the nerve was statistically greater (p < 0.05), averaging 7.9 mm in extension and 13.7 mm in flexion. The remaining anterolateral portal, located 1 cm directly anterior to the lateral epicondyle, was found to be at a statistically greater average distance from the nerve than was the distal anterolateral portal but statistically closer than was the more proximal portal. The ability to visualize the joint arthroscopically was assessed using the three portals, and although the ulnohumeral joint could be adequately seen using all portals, radiohumeral joint visualization was most complete and technically easiest using the most proximal portal. The proximal anterolateral portal, used in >100 elbow anthroscopies without evidence of radial nerve injury, is recommended for use as the standard lateral access site, allowing excellent visualization while maximizing the distance from the radial nerve throughout the elbow's range of motion.     

Advancements in ankle arthroscopy

Important progress has been made during the past 30 years in arthroscopic ankle surgery. Ankle arthroscopy has gradually changed from a diagnostic to a therapeutic tool. Most arthroscopic procedures can be performed by using the anterior working area with the ankle in dorsiflexion or plantar flexion; there is no need for routine ankle distraction. Anterior ankle problems, such as anterior impingement syndrome, are approached by anteromedial and anterolateral portals and, if necessary, an accessory portal. Most osteochondral defects can be reached from anterior with the ankle in plantar flexion. For a far posterior location, the osteochondral defect can be approached from posterior. The two-portal hindfoot endoscopic technique (ie, both arthroscopic and endoscopic surgery), with the patient in the prone position, provides excellent access to the posterior ankle compartment and to posteriorly located extra-articular structures.     

Ankle arthroscopy with patient in prone position

Anterior ankle arthroscopy is the most commonly performed foot and ankle arthroscopy. By means of the anterolateral and anteromedial portals, the anterior compartment of the ankle joint can be approached easily. Different posterior portals had been described to reach the posterior ankle compartment. With the patient in prone position and the combination of anterior and posterior portals, the medial and lateral gutters of the ankle joint can be reached together with the anterior and posterior compartment. This is useful for complete synovectomy of the ankle joint.     

Arthroscopy of the elbow: Anatomy,portal sites,and a description of the proximal lateral portal

Cadaveric studies were carried out to evaluate the safety and value of the standard portals used in elbow arthroscopy. The dissections were performed in 12 fresh cadaveric specimens. Each portal was assessed in terms of its safety with respect to nearby important structures. A proximal lateral portal was evaluated and has subsequently been used in 62 patients. A straight posterior (transhumeral) portal was also studied. We have found that in arthroscopy of the elbow joint, the proximal approaches (proximal medial and proximal lateral), are safer than the anteromedial and anterolateral approaches. All areas of the anterior compartment can be visualized using these two portals, and we recommend that they be the standard anterior portals used in elbow arthroscopy. All of the posterior approaches are safe.     

Competence of the deltoid ligament in bimalleolar ankle fractures after medial malleolar fixation

BACKGROUND: The stability of the ankle joint is provided by the medial and lateral malleoli and ligaments. Recent studies of cadaveric ankles have demonstrated that injury to the medial structures of the ankle is necessary to allow lateral subluxation of the talus after fracture. However, cadaveric models are limited by the fracture pattern chosen for the model. We sought to investigate the competency of the deltoid ligament in vivo in patients with an operatively treated bimalleolar ankle fracture. METHODS: Twenty-seven patients with a bimalleolar ankle fracture were evaluated. In each patient, the medial malleolus was anatomically reduced and fixed. A radiograph of the ankle was then made with application of an external rotation load to the joint. All lateral malleolar injuries were then reduced and fixed. The radiographs were evaluated for restoration of the competence of the deltoid ligament according to established criteria. RESULTS: Seven (26 percent) of the twenty-seven patients had radiographically evident incompetence of the deltoid ligament after medial malleolar fixation. This finding was associated with a small medial malleolar fragment. CONCLUSIONS: In bimalleolar fractures, the medial injury may be an osseous avulsion, leaving the deltoid intact on the displaced fragment, or it may be a combination of ligamentous and osseous injury with disruption of the deep portion of the deltoid ligament.     

Anatomical structures at risk in the arthroscopic Broström-Gould procedure: A cadaver study

BackgroundThe Broström Gould procedure is the gold standard for repair of lateral ankle ligament injury and ankle instability. This procedure has demonstrated excellent short- and long-term outcomes in the orthopedic literature. Arthroscopic Broström Gould techniques have become increasingly popular among some foot and ankle orthopedic surgeons. Typically, this technique requires standard anteromedial and anterolateral portals along with an accessory lateral working portal. The exact location of this portal is variable within the available described surgical techniques. The objective of this cadaveric study is to establish a standard entry point for and to assess the safety of the accessory lateral portal with respect to nearby anatomical structures.MethodsTen fresh-frozen below-knee cadaver specimens were used. The location of the accessory lateral portal was created 1.5 cm anterior to the distal tip of the fibula. A small vertical incision was made at this point, followed by insertion of a Kirschner wire into the joint. The wire was then gently impacted into the fibula. Superficial dissection was subsequently carried out around the entry point to identify the peroneal tendons, superficial peroneal nerve branches, and sural nerve branches. Structures were marked with colored push pins, and distance was measured between the nearest edge of the Kirschner wire and each of the three anatomic structures listed. Any instances of structural contact or damage were documented.ResultsThe average distance from the Kirschner wire to the peroneal tendon was 16.1 (±4.41) mm. The average distance from the wire to the superficial peroneal nerve and sural nerve was 13.11 (±6.79) mm and 12.33 (±4.08) mm, respectively. There were no instances of injury to any of the studied structures. However, there was a notable amount of variability in the proximity of structures in question for each cadaver. A branch of the superficial peroneal nerve was measured as close as 2 mm and as far as 24 mm in separate cadaver specimens.ConclusionArthroscopic Broström Gould procedures are a safe and effective method for lateral ankle ligamentous repair but are not without risk. Accessory lateral portal placement is relatively safe but should be meticulously executed to avoid damage to nearby anatomical structures.     

Usefulness of the Medial Portal during Hip Arthroscopy

The current conventional portals for hip arthroscopic surgery are the anterior, anterolateral, and posterolateral portals. For lesions in the medial anteroinferior or posteroinferior portion of the hip, these portals provide insufficient access to the lesion and consequently lead to incomplete treatment. Thus, in such a situation, a medial portal approach might be helpful. However, operators have avoided this procedure because of the risk of injury to the obturator, femoral neurovascular structures, and the medial femoral circumflex artery. Thus, to overcome the disadvantages of the conventional method for medial lesions of the hip, we performed a cadaveric study to evaluate the technique, usefulness, and risk of the medial portal technique.     

Anatomic relationship between elbow arthroscopy portals and neurovascular structures in different elbow and forearm positions

Twenty fresh cadaveric elbows were used to evaluate the proximity of neurovascular structures to the six arthroscopic portals of the elbow at different positions. After distention of the joint, 4-mm Steinmann pins were introduced into the elbow from the portal's entry points. After surgical dissection, the proximity of the neurovascular structures to the pins was measured in 5 different positions. The radial nerve showed significant proximity to the anterolateral portal in full elbow flexion, full elbow extension, and forearm supination with 10%, 20%, and 10% nerve-pin contacts, respectively. The distance between the median nerve and medial portals was significantly decreased with full extension. This study demonstrated that the distance between the route of the scope and neurovascular structures might diminish significantly during elbow motion. Most of these movements are unavoidable in elbow arthroscopy, but maintaining certain positions for a considerable period of time or angulating the scope forcefully in these positions can cause nerve injury.     

Pseudoaneurysm of the Medial Superior Genicular Artery after Arthroscopic Partial Meniscectomy

We describe a case of 43-year-old man who had a pseudoaneurysm of the medial superior genicular artery after arthroscopic partial meniscectomy with standard anterolateral and anteromedial portals. Pseudoaneurysm of the medial superior genicular artery has been reported at the previous superomedial portal site after arthroscopy. Described herein is a unique case that involved the medial superior genicular artery at the previous anteromedial portal site after arthroscopy. The pseudoaneurysm was successfully treated with transcatheter embolization.     

Risks of neurovascular injury in elbow arthroscopy: starting anteromedially or anterolaterally?

A cadaver dissection study was performed to study the risks of neurovascular damage in elbow arthroscopy. The risk of injury to the radial nerve in the anterolateral approach was higher than the risk of damaging the median nerve in the anteromedial approach. In addition, starting medially may contribute to accurate placement of the anterolateral portal and may further help to decrease the risk of injuring the radial nerve. Therefore, starting with an anteromedial approach has several advantages above starting anterolaterally.     

Anatomic Study of Anterior and Posterior Ankle Portal Sites for Ankle Arthroscopy in Plantarflexion and Dorsiflexion: A Cadaveric Study in the Japanese Population

Arthroscopy is an important and minimally invasive diagnostic and therapeutic tool. However, the risk of injury to the neurovascular structures around the portals exists during arthroscopy of the ankle. In the present study, we measured the distance between each portal and the adjacent neurovascular structures with the foot in plantarflexion and dorsiflexion in the Japanese population. Standard anterolateral (AL), anteromedial, posterolateral (PL), and posteromedial portal positions were identified in 6 fresh adult cadaveric feet. The skin was dissected from the underlying tissue to visualize the adjacent neurovascular structures as noninvasively as possible. The superficial peroneal nerve was the structure closest to an anterior (i.e., AL) portal (3.2?±?4.2 and 8.3?±?3.9?mm in plantarflexion and 5.2?±?4.3 and 10.8?±?4.1?mm in dorsiflexion), followed by the saphenous nerve and great saphenous vein (SpV). The distance from the superficial peroneal nerve to the AL portal and from the saphenous nerve and great SpV to the anteromedial portal increased significantly with dorsiflexion and decreased significantly with plantarflexion. The sural nerve was the structure closest to the posterior (i.e., PL) portal (10.4?±?4.8?mm in plantarflexion and 8.5?±?3.9?mm in dorsiflexion), followed by the lesser SpV. The distance from the sural nerve, saphenous nerve, and lesser SpV to the PL portal and from flexor hallucis longus, posterior tibial artery, and tibial nerve to the posteromedial portal increased significantly in plantarflexion and decreased significantly in dorsiflexion. These findings could help to prevent damage to the neurovascular structures during ankle arthroscopy.     

Posterior Tibial Tendon Rupture Associated With Anterolateral Distal Tibial and Medial Malleolar Fracture and a Novel Pattern of Tibiofibular Syndesmotic Injury: A Case Report and Review of the Literature

A posterior tibial tendon (PTT) rupture associated with ankle fractures is a very rare condition. Ankle pronation and external rotation (PER) movement are the typical traumatic mechanism. This injury is frequently overlooked preoperatively. Early diagnosis and treatment are very important to prevent the serious consequences related to functional PTT insufficiency on biomechanics of the foot. Few cases have been described in the literature that highlight the relationship between PTT rupture and PER type ankle fracture with a medial malleolar fracture. We present a case of a complete PTT rupture in a closed atypical ankle fracture in which a medial malleolar fracture was associated with a very large fragment from the anterolateral distal tibia (Tillaux-Chaput fragment) and a concomitant avulsion fracture from the anteromedial portion of the fibula (Lefort-Wagstaffe fragment), with a novel pattern never described before.     

A View From Above: A Modified Patel’s Medial Midpatellar Portal for Anterior Cruciate Ligament Arthroscopic Surgery

The use of flexible positions based on the surgeon’s need to address specific pathology has been advocated in arthroscopic surgery. In this report we reappraise the midpatellar portals popularized by Patel and present a technique modification of the medial midpatellar portal (mMPP) focusing on its use in anterior cruciate ligament primary and revision arthroscopic surgery. The modified mMPP is established under arthroscopic control from a high anterolateral portal. Its location is more proximal than the original Patel’s mMPP. The nearly vertical orientation of the arthroscope and its proximity to the midline offer a wider and almost face-to-face visualization of the intercondylar notch in the coronal plane, which would provide advantages over standard portals. The anteromedial and anterolateral portals may both be used as working portals without crowding because the arthroscope is cranially located. The need to perform notchplasty is reduced, minimizing bleeding from trabecular bone. Aggressive soft-tissue processing in the intercondylar notch to improve visualization is seldom required. The recipient site is less devascularized, which may promote autograft healing. The modified mMPP may also facilitate femoral tunnel placement and setting of an interference screw. It is safe and reproducible and may add to the diagnostic and working capabilities of the knee arthroscopist.     

All-Inside Suture Technique Using Anterior Portals in Posterior Horn Tears of Lateral Meniscus

Methods for the repair of meniscal tears include inside-out, outside-in, and all-inside techniques. In this article an all-inside technique is proposed for the posterior horn of the lateral meniscus that takes advantage of the capacious posterolateral recess when the knee is flexed. A device consisting of a large needle with a buttonhole in the tip (previously used for inside-out suture of the medial meniscus) is used. This technique uses only anterior portals (anteromedial and anterolateral portals and an accessory lateral or transpatellar tendon portal). The arthroscope is inserted through the accessory portal. Once the tear has been located and its edges refreshed, the suture device is placed anterolaterally. The tip of the needle is loaded with suture and passed through both sides of the tear and into the posterolateral recess of the knee (without exiting the capsule). The suture tail is recovered with the use of a suture retriever through the anteromedial portal. Next, the suture retriever is inserted through the anterolateral portal to once again retrieve and shuttle the tail before completion of an arthroscopic knot. In addition to the ease of the technique, use of this simple, reusable device adds the benefit of low cost when compared with other techniques.     

Chronic pain after ankle fracture: an arthroscopic assessment case series

BACKGROUND: The purpose of this study was to document findings of ankle arthroscopy in patients with residual complaints after an appropriately treated ankle fracture. METHODS: Patients who had ankle arthroscopy at the Alpine Orthosports Clinic between 1998 and 2000 were identified by a retrospective review of the ankle arthroscopy database. Fifty patients were identified who had arthroscopy for complaints after ankle fracture. The mean duration from injury to arthroscopy was 20.5 +/- 33.5 months, with a range of 2 to 184.6 months. RESULTS: There were 37 isolated fractures and 13 combination fractures. The Danis-Weber classification was used for lateral malleolar fractures. There were five type A, 14 type B, and 11 type C lateral malleolar fractures. RESULTS: Synovitis was present in 46 ankles and was located anterolaterally in 36. Synovitis was noted in 26 of the 30 ankles that had a lateral malleolar fracture. Arthrofibrosis was found in 20 ankles, with anterolateral joint involvement in 16. There was chondral damage noted in 45 ankles, 30 located on the talus and 15 on the tibia. Spurs were found in 15 ankles, and nine had loose bodies or debris. There were two postoperative complications: one patient had bleeding from a portal and the other had an area of paresthesia at the anterolateral portal site. CONCLUSION: Synovitis and chondral damage were more frequent than arthrofibrosis and spurs. Synovitis and arthrofibrosis were found most frequently in the anterolateral aspect of the joint. Also, the higher the lateral malleolar fracture was in relation to the syndesmosis, the higher was the occurrence of talar chondral damage.