内侧半月板后角“隐匿性”层裂14例报告

目的探讨内侧半月板后角"隐匿性"水平撕裂伤的临床特点及关节镜下半月板部分切除术的临床疗效。方法 2011年5月~2013年5月对14例内侧半月板后角"隐匿性"层裂采取膝关节前内、外侧入路关节镜探查,咬除半月板后角内缘后显露层裂,术中探查半月板后角底层不稳,切除底层后行半月板后角成形术。结果术中探查均为内侧半月板后角"隐匿性"层裂,6例半月板边缘及上下关节面均完整,8例水平撕裂延伸至胫骨关节面。平均手术时间32 min(26~40min),平均住院时间6 d(3~8 d)。术后切口均一期愈合,未发生膝关节感染、僵硬等并发症。14例随访2~3年,术后症状缓解,术前Lysholm评分(71.1±6.6)分,术后(92.0±3.4)分,术前后差异有统计学意义(t=10.530,P=0.000)。结论内侧半月板后角"隐匿性"层裂主要为退变性破裂,多合并软骨退变损伤,临床诊断较困难,仔细体格检查及MRI对诊断具有指导意义,关节镜下部分切除成形术可改善膝关节功能。     

前交叉韧带退变与髁间窝撞击及内侧半月板撕裂的相关性研究

目的探讨膝骨关节炎(knee osteoarthritis,KOA)患者前交叉韧带(anterior cruciate ligament,ACL)退变与髁间窝撞击、内侧半月板撕裂间的相关性。方法回顾分析2014年7月-2016年2月收治伴ACL退变的KOA患者55例(55膝,退变组)临床资料,另随机选择55例(55膝)ACL正常的KOA患者作为对照(55膝,正常组)。两组患者性别、年龄、体质量指数、侧别比较,差异均无统计学意义(P0.05)。于术前MRI测量髁间窝指数,评价是否存在髁间窝狭窄;关节镜下观察内、外侧半月板撕裂发生情况以及发生部位,有无ACL胫骨止点骨赘形成;计算各部位半月板撕裂及骨赘形成发生率。结果两组内侧半月板前角、体部撕裂发生率,外侧半月板前角、体部、后角及后根部撕裂发生率比较,差异均无统计学意义(P0.05);内侧半月板后角及后根部撕裂发生率、ACL胫骨止点骨赘形成发生率、髁间窝狭窄发生率以及髁间窝指数比较,差异均有统计学意义(P0.05)。两组13例存在ACL胫骨止点骨赘患者中,内侧半月板后根部撕裂发生率为53.8%(7/13);97例无ACL胫骨止点骨赘患者中,其发生率为16.5%(16/97);比较差异有统计学意义(χ~2=9.671,P=0.002)。结论 KOA患者ACL退变与髁间窝撞击以及内侧半月板后角、后根部撕裂密切相关,ACL胫骨止点骨赘形成与内侧半月板后根部撕裂发生率相关。     

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。     

同种异体半月板移植的研究现状

1 研究背景 1.1半月板的解剖与功能 半月板是膝关节内的软骨盘,位于胫骨平台与股骨髁之间,内侧为C型,外侧为近似O型.均分为前角、后角和体部.前后角借助"止点"结构固定于胫骨平台,内侧半月板前角止于胫骨髁间前斜坡处,后角止于内侧髁间棘后侧、后交叉韧带止点之前;外侧半月板前角止于外侧髁间棘前部,部分纤维与前交叉韧带相延续,后角止于外侧髁间棘后缘.     

膝关节半月板撕裂的磁共振表现

目的进一步认识膝关节半月板撕裂的磁共振成像(MRI)表现。方法回顾分析50例膝关节半月板撕裂的MRI资料,所有病例均经关节镜手术证实。采用永磁型MRI机,场强0.2T。结果50例半月板撕裂中,按照部位分类,半月板撕裂位于内侧半月板前角2例,内侧后角37例,外侧半月板前角5例,外侧后角3例,同时累及半月板前角、体部和后角者内侧2例,外侧1例。按照半月板撕裂的形式分为:水平撕裂8例;垂直撕裂4例;斜形撕裂26例;纵形撕裂3例;放射状撕裂4例;桶柄状撕裂2例;复杂撕裂3例。结论MRI能够清楚显示膝关节半月板撕裂的部位和形式,为临床治疗提供可靠的依据,是目前诊断半月板撕裂的最好的影像学检查方法。     

双膝内侧盘状半月板1例

膝关节盘状半月板又称盘状软骨,是解剖学上出现的一种异常症状,多发生在外侧,内侧少见,而发生于双膝内侧更是极为罕见。主要治疗以关节镜手术为主。我院2010年6月收治1例双膝内侧盘状半月板,行关节镜下盘状半月板成形术,效果满意,现报告如下。     

膝内侧副韧带松解技术在内侧间室狭窄半月板损伤关节镜手术中的应用

目的探讨经皮针刺拉花松解膝内侧副韧带技术在内侧间隙狭窄内侧半月板损伤关节镜手术中用于扩大膝关节内侧间隙的有效性和安全性。方法回顾性分析自2018-05—2019-09采用关节镜手术治疗的16例合并膝内侧间隙狭窄的内侧半月板损伤,术中采用经皮针刺拉花松解内侧副韧带技术增加膝内侧间室的镜下显露范围与手术操作空间,顺利完成半月板部分切除或修复手术。结果 16例均获得随访,随访时间平均10(6~18)个月。所有患者均无医源性骨软骨损伤及血管神经损伤。4例术后出现膝关节内侧副韧带松解处疼痛、皮下瘀斑,术后2周逐渐缓解。术后3例外翻应力试验Ⅰ度阳性,术后1个月转为阴性。膝内侧副韧带松解前膝关节最大外翻位时膝内侧间隙为(7.6±1.3)mm,松解后为(12.1±1.4)mm,差异有统计学意义(P<0.05)。结论对于采用关节镜手术治疗的膝内侧间隙狭窄的内侧半月板损伤患者,经皮针刺拉花松解膝内侧副韧带技术简单可靠、安全有效,可增大关节镜手术中膝关节内侧间室手术视野和操作空间,有利于进行半月板部分切除或修复,避免了医源性骨软骨损伤。     

关节镜下半月板全切手术方法探讨(附169例报道)

目的 探索一种新的利用简单器械进行关节镜下半月板全切除的手术方法。方法 总结1992年11月～1998年8月,利用直向半月板切除刀、钩刀、提蓝打孔器等简单器械进行关节镜下半月板全切除手术169例。结果 半月板全切术平均手术时间为78分钟,术中未见损伤关节软骨和韧带,术后仅7．9％的患需要肌肉注射止痛剂,8例有一过性止血带麻痹,所有患2周后均可从事工作及开始运动训练。结论 本方法与David Sisk介绍的方法相比,要求器械简单、切口少、合并症少、创伤小,且同一种方法可适应于内、外侧半月板,是一种安全的、较好的手术方法。     

膝关节半月板根部附着区的解剖学测量

目的:测量国人膝关节内外侧半月板前后根部附着区的解剖学数据,为临床修复半月板根部损伤提供解剖学基础。方法:选取30个国人成人尸体膝关节标本,其中男16例,女14例;死亡年龄35～68(55.6±7.8)岁。对半月板根部附着区结构进行解剖,测量内外侧半月板根部附着区中心点与胫骨内外侧髁间棘、后交叉韧带前缘、内侧胫骨平台软骨后方外侧缘及外侧胫骨平台软骨后方内侧缘等标志点的位置关系和各个附着区的面积。结果:内侧半月板后根部附着区:中心点位于胫骨内侧髁间棘后方(11.73±3.10) mm、外侧(2.77±0.86) mm,后交叉韧带前缘前(2.76±0.76) mm,内侧平台软骨外侧缘外(3.92±0.22) mm,附着区面积(31.29±5.18) mm~2。内侧半月板前根部附着区:中心点位于胫骨内侧髁间棘前方(25.40±5.27) mm、外侧(3.01±0.86) mm,附着区面积(46.18±11.60) mm~2。外侧半月板后根部附着区:中心点位于胫骨外侧髁间棘后方(4.51±1.35)mm、内侧(1.85±0.34) mm,后交叉韧带前缘前(6.91±1.11) mm,外侧平台软骨内侧缘内(3.16±0.96) mm,附着区面积(44.10±6.23) mm~2。外侧半月板前根部附着区:中心点位于胫骨外侧髁间棘前方(12.97±2.92) mm、外侧(1.31±0.22) mm,附着区面积(60.84±14.98) mm~2。结论 :该试验定量描述内外侧半月板前后根部附着区的面积以及其中心点与相应标志点的位置关系,为临床修复半月板根部损伤提供一定的解剖学参考。     

膝关节半月板损伤的关节镜微创治疗

目的 探讨膝关节半月板损伤在关节镜下治疗的方法以及疗效。方法 对165例膝关节半月板损伤患者应用膝关节镜诊治进行回顾性分析本组施行半月板部分切除成形术127例（其中包括部分切除及囊肿切除3例．盘状半月板部分切除成形术12例），大部分切除13例，全切除2例，表面修整10例，修补13例；同时行镜下前交叉韧带重建术47例，后交叉韧带重建7例，前、后交叉韧带同时重建2例，内侧皱襞切除术15例。结果137例患者后术后复查，追踪时间2～32个月，81例平均Lysholm-II评分为92分（前、后交叉韧带重建术56例不参与评分），较术前提高49分。结论 应用关节镜进行治疗半月板损伤可达到最大限度保留半月板，创伤小、恢复快、疗效佳，并可同时处理其他病变，诊断准确性高，避免漏诊。     

中老年膝内侧半月板后角放射裂的临床研究

目的讨论膝内侧半月板后角放射状撕裂的临床特点和关节镜下半月板部分切除术后的随访结果。方法自2000年6月至2006年6月对386例（418膝）关节镜下治疗的膝内侧半月板撕裂患者进行回顾性研究,其中后角放射状撕裂93膝（22．2％）,全部行半月板部分切除术。在详细的手术记录和关节镜图像资料基础上,分析患者术前体征、MRI结果、术中所见和术后Lysholm膝关节评分。结果中老年患者中膝内侧半月板后角放射状撕裂有较高的发生率,大多数患者表现出机械卡压或撞击症状,MRI很难发现这种撕裂,有特点的疼痛症状和物理检查有助于诊断。虽然大多数患者年龄较大,关节软骨已发生退变,但关节镜下半月板部分切除术后,症状会明显改善。结论膝内侧半月板放射状撕裂比较常见,但因为多数患者同时伴有骨关节炎症状,且MRI上假阴性率较高,诊断比较困难。在严格掌握手术指征下,关节镜下半月板部分切除术有助于改善症状。     

Arthroscopic partial meniscectomy of a posteriorly flipped superior leaflet in a horizontal medial meniscus tear using a posterior transseptal portal

This article describes a case of an arthroscopic partial meniscectomy of a posteriorly flipped superior leaflet in a horizontal medial meniscus tear using the posterior transseptal portal. An arthroscopic partial meniscectomy for bucket handle or flap tears in medial or lateral compartments using ordinary portals is a relatively common procedure in irreparable cases. However, the posterior compartment of the knee is not readily accessible through ordinary arthroscopic portals. Therefore, it has been considered a blind spot. Through the posterior transseptal portal, surgeons can achieve excellent arthroscopic visualization of the posterior compartment and easily perform arthroscopic procedures of the posterior compartment of the knee. A 48-year-old woman presented with a 1-year history of pain in the medial aspect of the right knee joint. Preoperative magnetic resonance imaging revealed a thinning of the medial meniscus posterior horn in coronal images and a sharp-edged triangle arising from the medial meniscus posterior horn between the medial femoral condyle and medial meniscus posterior horn on sagittal images (flipped-over sign). During the arthroscopic procedure, we found that the flipped leaflet was displaced posteriorly and was not mobile between the medial femoral condyle and medial meniscus posterior horn. Partial meniscectomy for a posteriorly displaced fragment can be performed successfully using the posterior transseptal portal. The posterior transseptal portal is useful for an arthroscopic partial meniscectomy of a posteriorly flipped leaflet in the posterior compartment of the knee.     

The long-term evaluation of lateral meniscus tears left in situ at the time of anterior cruciate ligament reconstruction

Purpose: The goal of this study was to determine the long-term subjective and objective results for patients with lateral meniscus tears found at the time of anterior cruciate ligament (ACL) reconstruction that were left in situ or abraded and trephined but not repaired or removed. Type of Study: Retrospective review of prospectively collected data. Methods: From a database of ACL reconstruction patients, 332 patients were noted to have lateral meniscus tears that were left in situ or underwent abrasion and trephination. Exclusion criteria included lateral or medial partial meniscectomy, previous knee surgery, or greater than grade II chondromalacia in any knee compartment. The tears were classified as posterior horn tears (n = 70), stable radial flap tears (n = 50), or peripheral or posterior tears (n = 212). Patients were evaluated subjectively using a modified Noyes knee questionnaire and objectively using International Knee Documentation Committee (IKDC) criteria. Results: At a mean of 6.6 years (range, 2 to 16.5 years) after surgery, the mean total modified Noyes score for 239 patients was 93.8 ± 7.6 points. At a mean of 5.1 ± 3.8 years after surgery, the objective IKDC evaluation showed that 163 of 170 (96%) patients had an overall rating of normal or nearly normal. Radiographic evaluation showed that 162 patients (95%) had a normal rating, 6 patients had a nearly normal rating and 2 patients had an abnormal rating. Of 332 patients, only 8 (2.4%) required subsequent surgery for the lateral meniscus. Conclusions: Lateral meniscus tears that are posterior horn tears, stable radial flap tears, or peripheral or posterior third tears that do not extend further than 1 cm in front of the popliteus tendon can be treated successfully with abrasion and trephination or by being left in situ. Level of Evidence: Level III, retrospective cohort study.     

半月板撕裂和切除对前交叉韧带断裂力学稳定性的影响

目的探讨半月板对前交叉韧带断裂及重建术后胫骨前向稳定性的影响。 方法收集2017年1月至2018年10月期间前交叉韧带重建患者,排除前交叉韧带部分断裂和多发韧带损伤病例。所有不稳定半月板撕裂均行半月板部分切除术,根据半月板损伤部位及程度进行分组。采用KT-1000测量术前、术后3个月和6个月的胫骨前平移量(ATT)。组间对照采用独立样本t检验。 结果共纳入158例前交叉韧带断裂患者,其中半月板正常组61例,内侧半月板后角撕裂组49例(19例为撕脱<总宽度40%;30例为撕脱≥总宽度40%);外侧半月板撕裂组35例(12例为撕脱<总宽度40%;23例为撕脱≥总宽度40%);内侧半月板前角或体部撕裂组13例(6例为撕脱<总宽度40%;7例为撕脱≥总宽度40%)。术前内侧半月板后角撕裂≥总宽度40%患者的胫骨前平移量较半月板正常患者明显增加,差异有统计学意义(t＝12.141,P<0.01)。术后3个月及6个月,各个半月板撕裂组的ATT值与半月板正常患者相比均无差异(P >0.05)。 结论内侧半月板后角撕裂与前交叉韧带断裂可增加膝关节的不稳定性,半月板部分切除术对前交叉韧带重建术后患者的膝关节稳定性无影响。     

Arthroscopic resection of a bucket handle tear of the meniscus: a technical note

Arthroscopic resection of bucket handle tears of the meniscus is difficult owing to the obstructed view of the posterior horn. It often requires an additional portal for access or additional tools. We describe a technique involving conventional tools including grasper, shaver, and basket forceps. No additional portal is required. The basket forceps are used to cut the anterior attachment of the tear, and the bucket handle is shaved to a suitable size. The grasper is then used to hold the remaining meniscus and move it to the posterior space. The posterior corner of the meniscus is then turned over so that its posterior horn can be seen and accessible for cutting. This technique is primarily for medial meniscectomy. For lateral meniscectomy, the conventional technique may suffice, as the lateral compartment can be easily expanded between the femur and tibia.     

膝关节内外侧半月板后根部撕裂的MRI诊断价值

目的:探讨MRI对膝关节内外侧半月板后根部撕裂的诊断价值。方法:回顾性分析2012年1月至2016年1月,关节镜下证实为半月板后根部撕裂的患者43例。其中男25例,女18例;年龄27~69(42.5±8.3)岁;右侧27例,左侧16例。由2名医师采用双盲法独立回顾性分析经关节镜证实的43例半月板后根部撕裂患者的MRI表现,计算MRI对半月板后根部撕裂的诊断敏感性、特异性和准确性,并计算膝关节韧带损伤及半月板脱位等伴随情况。结果:143例中,关节镜手术证实43例半月板后根部撕裂,包括内侧撕裂24例,外侧撕裂19例。医师A诊断内侧半月板后根部撕裂的敏感性、特异性、准确性分别为91.67%、86.6%、83.9%,伴内侧半月板突出19例,伴前交叉韧带撕裂2例;外侧半月板后跟部撕裂的敏感性、特异性、准确性分别为73.7%、79.9%、79%,伴外侧半月板突出4例,伴前交叉韧带撕裂16例。医师B诊断内侧半月板后根部撕裂的敏感性、特异性、准确性分别为87.5%、87.4%、87.4%,伴内侧半月板突出19例,伴前交叉韧带撕裂2例;外侧半月板后跟部撕裂的敏感性、特异性、准确性分别为78.9%、82.3%、82.5%,伴外侧半月板突出4例,伴前交叉韧带撕裂16例。2名医师采用MRI诊断内、外侧半月板后根部撕裂的一致性均好,Kappa值分别为0.81和0.67。结论 :膝关节MRI诊断内外侧半月板后跟部撕裂及其伴随征象具有较大价值,为临床医生术前诊断提供依据,值得临床推广应用。     

Microvasculature of the human medial meniscus: operative findings.

The purpose of our study was to weigh the probability of a successful meniscus repair on the basis of the microvasculature of the human medial meniscus. In a series of 105 patients who underwent an anterior cruciate ligament reconstruction between January 1985 and December 1986, we chose the 40 patients who had a subtotal medial meniscectomy (38%) to study the microvasculature of the human medial meniscus adequately; the other patients had either an intact meniscus (23%), a meniscus repair (29%), or an already removed meniscus (10%). Forty medial menisci, from 40 male patients with an average age of 27 years, having an anterolateral and/or anteromedial chronic knee laxity and an associated meniscal pathology, were subdivided into two groups: (a) 20 tears restricted to the posterior horn, and (b) 20 bucket-handle tears observed under light microscopy. Meaningful capillary plexuses penetrating into the meniscal stroma were found in 18 of 40 menisci (45%). They were easier to identify in posterior horn tears (55%) than in bucket-handle tears (35%), and were found especially in younger patients (22 years on the average). Therefore, we encourage meniscus repairs even in chronic tears, particularly in younger patients and in posterior-horn tears.     

膝关节外侧半月板假撕裂MRI征象分析及临床意义

目的:明确板股韧带及膝横韧带所致外侧半月板假撕裂的发生机制,探讨外侧半月板假撕裂与真撕裂的鉴别方法。方法:对自2012年6月至2014年2月间72例(左膝44例,右膝28例)经关节镜证实的无外侧半月板撕裂的膝关节进行矢状及冠状位MR扫描,其中男41例,女31例;年龄25～61岁,平均33.7岁。观察板股韧带及膝横韧带的MRI表现。结果:膝横韧带与外侧半月板前角及其中央腱性附着部之间以脂肪组织分隔,在MRI矢状像上,可见脂肪组织在膝横韧带与外侧半月板前角之间形成的线样稍高信号裂隙,类似外侧半月板前角撕裂,称为外侧半月板前角假撕裂。板股韧带在矢状像上表现为位于后交叉韧带前或后方的类圆形或短棒状低信号结构,而在冠状像上表现为自外侧半月板后角至股骨内侧髁外侧面的条带样低信号结构。在矢状像上,板股韧带与外侧半月板后角之间显示出一线样高信号,称为外侧半月板后角假撕裂。膝横韧带在MRI上的出现率约34.7%(25/72),表现为外侧半月板前角假撕裂18例,均表现为外侧半月板形态规则、撕裂线斜行,矢状位图像可连续显示膝横韧带,冠状位图像能显示该韧带的长轴。板股韧带显示率为73.6%(53/72),其中板股前韧带为23.6%(17/72),板股后韧带为70.8%(51/72),两条韧带同时存在为16.7%(12/72).表现为外侧半月板后角假撕裂25例,假撕裂仅有两种走行方向,即后下斜行(19/25)或垂直方向(6/25).结论:根据外侧半月板形状、撕裂线方向、观察矢状和冠状位图像,可正确区分外侧半月板的真、假撕裂。     

Arthroscopic All-Inside Repair of Tears of the Anterior Horn of the Lateral Meniscus

Presently, the outside-in or inside-out meniscal repair techniques are recommended for the repair of tears of the anterior horn of the lateral meniscus. However, an incision about 1 to 2 cm or more in length is needed, and the biomechanics of the lateral meniscus may be altered during motion. We have developed a new alternative repair technique to prevent this skin incision and preserve the normal biomechanics of the lateral meniscus during motion. We use 3 portals: a lateral patellofemoral axillary portal, a standard anterolateral portal, and an extreme far medial portal. We perform all-inside repair for tears of the anterior horn of the lateral meniscus using suture hooks.