窩囊腫的關(guān)節(jié)鏡治療

二、發(fā)病機制單向流通的“閥門機制”（只進不出）。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,通過平股骨髁腓腸肌內(nèi)側(cè)頭處的橫向裂隙樣結(jié)構(gòu)進入GSB,但不能從GSB流向關(guān)節(jié)腔,導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)病過程中起重要作用。Sansone等認為半月板尤其是內(nèi)側(cè)半月板損傷是致病的關(guān)鍵,84%-90%的患者可見有內(nèi)側(cè)半月板損傷。三、臨床表現(xiàn)Rauschning和Lndgren對腘窩囊腫評價分級如表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,可見粗細不一的光帶及散在點狀回聲,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)見密集光點回聲或粗斑點狀回聲,呈懸浮狀,可飄動,下垂部位可見回聲分層,此型可見于囊內(nèi)出血或感染。五、治療原則：有癥狀才處理。開放手術(shù)、關(guān)節(jié)鏡手術(shù)。開放手術(shù)：疤痕大，影響關(guān)節(jié)功能、易損傷血管神經(jīng)、易復發(fā)。（在囊腫切除時要同時將關(guān)節(jié)囊縫合）關(guān)節(jié)鏡手術(shù)：微創(chuàng)、恢復快、關(guān)節(jié)功能影響小，復發(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)是外科治療的主要目標!方法二：FIGURE1.(A)Schematiccross-sectionimageofthekneewiththeopeningoftheconnection.Theimageshowsthelocationoftheposteromedialportalandtheanterolateralviewingportal.(P,poplitealcyst.)(B)Arthroscopicfindingfromtheanterolateralportaloftherightkneeshowsaconnectinghole(curvedarrow)attheposteromedialcompartmentthatverifiestheretractionofthecapsularfold(C)byprobing(straightarrow).(M,medialfemoralcondyle.)FIGURE2.(A)Arthroscopicfindingfromtheanterolateralportaloftherightkneeshowsthatthecapsularfold(C)wasresectedbybasketforceps(arrow)insertedfromtheposteromedialportal.(B)Arthroscopicfindingfromtheanterolateralportaloftherightkneeshowsayellowishcysticfluidthatgushesouttotheposteromedialcompartmentbycompressingtheposteromedialpartskinoftheballoonedcyst.(M,medialfemoralcondyle.)FIGURE3.Arthroscopicfindingoftheanterolateralportaloftherightkneeshowsanopening(curvedarrow).Theopeningisshownattheposteromedialsideofthemedialheadofthegastrocnemius(G)afterthecapsularfoldwascompletelyresectedwithashaver(straightarrow)andbasketforceps.(M,medialfemoralcondyle.)FIGURE4.(A)Schematiccross-sectionalimageofthekneewiththeopeningoftheconnection.Theimageshowsthelocationoftheposteromedialviewingportal(b).(P,poplitealcyst.)(B)Arthroscopicfindingfromtheposteromedialportaloftherightkneeshowsseptationandloosefragmentsoftheinsideofthepoplitealcyst.FIGURE5.(A)Schematiccross-sectionalimageofthekneewiththeopeningoftheconnection.Theimageshowsthelocationoftheposteromedialviewingportal(b)andtheposteromedialcysticportal(c).(P,poplitealcyst.)(B)Grossviewoftherightkneejointthatwaspositionedforarthroscopicsurgeryforapoplitealcyst.Thearthroscopewasinsertedthroughtheposteromedialportal,andamotorizedshaverwasintroducedfromtheposteromedialcysticportal.(C)Arthroscopicfindingfromtheposteromedialportaloftherightkneeshowsthatamotorizedshaver(S)wasinsertedtotheinsideofthepoplitealcystthroughtheposteromedialportal.Thecystwall(W)wasresectedwiththeshaver.FIGURE6.(A)ApreoperativeMRimage(axialview)showsahugepoplitealcystwithmultipleseptation.(B)