1、Arthroscopic Treatment of Popliteal Cyst（腘窩囊腫的關(guān)節(jié)鏡治療）,-浙江省運(yùn)動(dòng)醫(yī)學(xué)中心 浙江省人民醫(yī)院運(yùn)動(dòng)醫(yī)學(xué)及關(guān)節(jié)外科 顧海峰,一、概述,早在1840年已經(jīng)被Adams所認(rèn)識(shí),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(guān)節(jié)腔相通。 臨床表現(xiàn)為關(guān)節(jié)疼痛及活動(dòng)受限。 分為原發(fā)性和繼發(fā)性兩種。,二、發(fā)病機(jī)制,單向流通的“閥門機(jī)制”（只進(jìn)不出）。 存在半膜肌與腓腸肌內(nèi)側(cè)頭滑液囊( GSB) 。 關(guān)節(jié)積液增多引起關(guān)節(jié)囊內(nèi)壓增高, 通過(guò)平股骨髁腓腸肌內(nèi)側(cè)頭處的橫向裂隙樣結(jié)構(gòu)進(jìn)入

2、GSB, 但不能從GSB流向關(guān)節(jié)腔,導(dǎo)致囊腫的形成和持續(xù)存在。 關(guān)節(jié)內(nèi)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(guò)程中起重要作用。 Sansone等認(rèn)為半月板尤其是內(nèi)側(cè)半月板損傷是致病的關(guān)鍵, 84%-90%的患者可見(jiàn)有內(nèi)側(cè)半月板損傷。,三、臨床表現(xiàn),Rauschning和Lndgren對(duì)腘窩囊腫評(píng)價(jià)分級(jí)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(guān)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(guān)節(jié)腔相通, 有寬窄不一的蒂

3、部管狀結(jié)構(gòu),囊腫形態(tài)欠規(guī)則呈多樣性, 囊壁厚薄不均, 可見(jiàn)粗細(xì)不一的光帶及散在點(diǎn)狀回聲, 探頭加壓囊腫形態(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(nèi)見(jiàn)密集光點(diǎn)回聲或粗斑點(diǎn)狀回聲,呈懸浮狀,可飄動(dòng),下垂部位可見(jiàn)回聲分層,此型可見(jiàn)于囊內(nèi)出血或感染。,五、治療,原則：有癥狀才處理。 開(kāi)放手術(shù)、關(guān)節(jié)鏡手術(shù)。 開(kāi)放手術(shù)：疤痕大，影響關(guān)節(jié)功能、易損傷血管神經(jīng)、易復(fù)發(fā)。（在囊腫切除時(shí)要同時(shí)將關(guān)節(jié)囊縫合） 關(guān)節(jié)鏡手術(shù)：微創(chuàng)、恢復(fù)快、關(guān)節(jié)功能影響小，復(fù)發(fā)率低。,六、關(guān)節(jié)鏡手術(shù)的方法,方法一：,成功治療的關(guān)鍵是膝關(guān)節(jié)內(nèi)相關(guān)病損的處理和重建滑囊與關(guān)節(jié)腔正常的雙向流通,囊腫本身不應(yīng)是外科治療的主要

4、目標(biāo)!,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 portal. (P, popliteal cyst.) (B) Arthroscopic finding from the anterolateral portal of the right knee shows a co

5、nnecting hole (curved arrow) at the posteromedial compartment that verifies the retraction of the capsular fold (C) by probing (straight arrow). (M, medial femoral condyle.),2020/7/7,11,.,FIGURE 2. (A) Arthroscopic finding from the anterolateral portal of the right knee shows that the capsular fold

6、(C) was resected by basket forceps (arrow) inserted 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 posteromedial compartment by compressing the posteromedial part skin of the ballooned cyst

7、. (M, medial femoral condyle.),FIGURE 3. Arthroscopic finding of the anterolateral portal of the right knee shows an opening (curved arrow). The opening is shown at the posteromedial side of the medial head of the gastrocnemius (G) after the capsular fold was completely resected with a shaver (strai

8、ght arrow) and basket forceps. (M, medial femoral condyle.),FIGURE 4. (A) Schematic cross-sectional image of the knee with the opening of the connection. The image shows the location of the posteromedial viewing portal (b). (P, popliteal cyst.) (B) Arthroscopic finding from the posteromedial portal

9、of the right knee shows septation 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 portal (b) and the posteromedial cystic portal (c). (P, p

10、opliteal 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 posteromedial portal, and a motorized shaver was introduced from the posteromedial cystic portal. (C) Arthroscopic finding from the poste

11、romedial portal of the right knee shows that a motorized shaver (S) was inserted to the 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)