半月板损伤的治疗策略

Loss of meniscal function leads to progressive degenerative joint disease 半月板缺失导致继发性关节退变
半月板切除术
• 部分切除 • 次全切除 • 全切除
半月板切除术
半月板缝合
•红__红区 (最佳愈合区) •红__白区 (良好愈合区) •白__白区 (较差愈合区?)
• deformation under loading forces fluid flow through the meniscus matrix which has a low permeability thereby absorbing and dissipating energy which attenuates shocks from impact loading 负载时,半月板的变形吸收分散了能量
Joint Stability稳定关节
• increases joint congruity 增强关节协调性 • following an ACL tear, the posterior horn of the medial meniscus
helps to limit further AP translation of the tibia (secondary restraint) ACL撕裂时,半月板后角限制胫骨的前后平移
Knee Joint Changes after Meniscectomy T.J. Fairbanks
JBJS 30B, November 1948
The Fibrous Structure of the Meniscus
• circumferential “hoop” fibers • superficial randomly oriented fibers • radially oriented “tie” fibers
• viscoelastic properties of the meniscus result in a 20% higher shock-absorbing capacity in normal knee compared with post-meniscectomy knees 和半月板全切后的膝关节比较,半月板的弹性特征使 得其震动吸收率超过20%
Other Functions of the Meniscus
Lubrication 润滑
• proposed role in distributing joint fluid between the femoral and tibial articulating surfaces as a result of their crescent and circular-like shapes
优点
切口小 无需专用器械
缺点
缝合位置困难,适用于半月板前角撕裂
半月板修补技术：All-inside
器械经通道穿过半月板，达到能够 释放 ‘T’的深度.
当２个 ‘T’使用后，在关节外打结， 使用推结器将结推到半月板旁
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成功的半月板修补需要
适当的撕裂和病人选择 撕裂位置的刺激 撕裂位置的稳定 撕裂位置的术后保护
半月板修复的理想适应症
• Vertical longitudinal tear in the peripheral outer third of the meniscus
• Stable knee or a knee in which an ACL reconstruction is to be performed
Proprioception 本体感觉
• mechanoreceptors found in the anterior and posterior horns of the meniscus
• extremes of flexion and extension place stress on the horns of the menisci which could activate the mechanoreceptors and provide the CNS with joint position information
Popliteal Artery
Popliteal Vein
Peroneal Nerve
Saphenous Nerve
Fra Baidu bibliotek
半月板修补
Inside-out: 双套管缝合修补系统 选择合适的套管有效放置于撕裂的半月板处，进行有效的缝合修补
半月板
Inside-out:双套管缝合修补系统 双针通过套管穿过撕裂的半月板、关节囊及先前建立的小切口（要注意缝合针 的穿过要避开神经血管组织）
造成新鲜创面，以利愈合
半月板撕裂处的打磨
纤维蛋白原凝块
缝合位置
由于半月板胶原纤维的环行方向， 垂直缝合具有最佳的固定强度
半月板缝合术
缝合方法: Inside-out Outside-in All-inside
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半月板修补:Inside-out
例如 ：半月板缝针套装 需要最开始建立一个小的后侧切口,来 防止损伤腘动、静脉，腓总神经，隐 神经等
• partial meniscectomy decreases contact area by 10% and increases peak loads by only 60% 半月板局部切除后,如果接触面积减少10%峰值重力增加60%
Load Transmission传输重力
Shock Absorption 吸收震动
“Changes in the knee joint after
meniscectomy include ridge formation , narrowing of the joint space and flattening of
the femoral condyle. Investigatons suggest that these changes are due to loss of the weight-bearing function of the meniscus.”
能垂直或水平缝合
半月板修补技术inside-out 优势 良好的视野 良好的缝线位置
劣势 神经血管组织的损伤危险 需要后切口
半月板修补技术：Outside-in
做一个小切口 • 通过切口将腰穿针套管穿入关节 • 缝线通过针穿过半月板进入关节 • 缝线被抓住后通过一个穿线器 从第二个腰穿针 中引出 • 当缝线的两端均在关节外，打结 • 注意不要结扎任何神经血管结构
• 50% of compressive load transmitted in extension, 85% at 90°flexion 膝关节伸展时传输50%的压力而屈曲90度时传输80%的压力
• total meniscectomy decreases tibial-femoral contact area by 75% resulting in a 235% increase in peak loads 半月板全切后胫骨和股骨接触面积减少75%导致峰值重力增加 235%
半月板损伤的治疗策略
半月板解剖
半月板的血运解剖
半月板的血运解剖
半月板功能
传递负重 吸震 关节稳定 润滑及营养关节 本体感觉
Load Transmission 传输重力
• converts axial loads to circumferential stress 把轴向重力转换成环向力量
• knee joint reaction force 2 – 5 times body weight during ADL (activities of daily living) up to 24 times body weight during high impact activities 日常生活中膝关节承受着2-5倍的体重反作用力而激烈运动时这 个重量高达24倍体重