本文選題：關(guān)節(jié)鏡　切入點(diǎn)：屈曲　出處：《西南醫(yī)科大學(xué)》2017年碩士論文

【摘要】：目的:通過(guò)30°和70°關(guān)節(jié)鏡對(duì)不同肘關(guān)節(jié)鏡入路的鏡下解剖視野進(jìn)行分析,選擇有效(視野佳、入鏡容易、鏡子操作靈活)的肘關(guān)節(jié)屈曲最適角度,為肘關(guān)節(jié)鏡手術(shù)在臨床上的應(yīng)用提供實(shí)驗(yàn)解剖基礎(chǔ)。方法:(1)將冰凍的肘關(guān)節(jié)標(biāo)本解凍;(2)標(biāo)記及固定體位:仔細(xì)觸摸體表的骨性解剖標(biāo)志,并標(biāo)記上臂和前臂的內(nèi)外側(cè)軸線(xiàn)、尺骨鷹嘴、肱骨內(nèi)上髁、肱骨外上髁等的位置,采用俯臥位方式將解凍的肘關(guān)節(jié)標(biāo)本固定在外支架上;(3)建立入路點(diǎn):通過(guò)游標(biāo)卡尺準(zhǔn)確測(cè)量且標(biāo)記肘關(guān)節(jié)鏡所需測(cè)量的入路點(diǎn);(4)建立通道:選用中外側(cè)入路注入20ml水膨脹肘關(guān)節(jié)腔。首先在近端前內(nèi)側(cè)入路點(diǎn)作一個(gè)僅切開(kāi)到皮下約3~4mm的切口,然后用直型止血鉗分離皮下軟組織,再用腰穿針向肘關(guān)節(jié)中心穿刺,有水流出后拔出腰穿針換用穿刺錐穿刺到肘關(guān)節(jié)中心,最后用帶有鏡鞘的穿刺錐穿入肘關(guān)節(jié)腔并留在關(guān)節(jié)腔中,保持鏡鞘穩(wěn)定后拔出穿刺錐,有水流出后分別插入4.0mm的30°和70°關(guān)節(jié)鏡;整個(gè)過(guò)程中懸掛3L袋生理鹽水3米左右高度持續(xù)保持壓力。采用建立近端前內(nèi)側(cè)入路的方法建立前內(nèi)側(cè)入路、前外側(cè)入路、外側(cè)垂直入路、前上外側(cè)入路、近端前外側(cè)入路、中外側(cè)入路、后正中入路和后外側(cè)入路,在此入路上探索新的入路;(5)觀(guān)察測(cè)量:通過(guò)不斷屈曲肘關(guān)節(jié)在30°和70°關(guān)節(jié)鏡下觀(guān)察到有效(視野佳、入鏡容易、鏡子操作靈活)時(shí)測(cè)量其肘關(guān)節(jié)屈曲最適角度,助手保持肘關(guān)節(jié)屈曲位置,用320°測(cè)量角度器(精確到l°)測(cè)量其數(shù)據(jù)并記錄影像學(xué)資料。采用SPSS19.0統(tǒng)計(jì)軟件進(jìn)行數(shù)據(jù)分析,數(shù)據(jù)采用均數(shù)±標(biāo)準(zhǔn)差(х±s)表示。結(jié)果:近端前內(nèi)側(cè)入路、前內(nèi)側(cè)入路、前外側(cè)入路、外側(cè)垂直入路在70°關(guān)節(jié)鏡下分別屈曲肘關(guān)節(jié)(82.90±2.38)°、(84.80±5.41)°、(84.90±2.47)°、(81.20±3.46)°時(shí)觀(guān)察該入路對(duì)側(cè)的肘關(guān)節(jié)腔內(nèi)解剖結(jié)構(gòu)是視野佳、入鏡容易、鏡子操作靈活的入路;近端前外側(cè)入路、前上外側(cè)入路在30°關(guān)節(jié)鏡下分別屈曲肘關(guān)節(jié)(82.90±4.46)°、(79.40±2.46)°時(shí)觀(guān)察該入路對(duì)側(cè)的肘關(guān)節(jié)腔內(nèi)解剖結(jié)構(gòu)是視野佳、入鏡容易、鏡子操作靈活的入路;中外側(cè)入路、后正中入路、后外側(cè)入路在70°關(guān)節(jié)鏡下分別屈曲肘關(guān)節(jié)(71.00±5.14)°、(61.10±3.70)°、(64.30±2.67)°時(shí)觀(guān)察該入路對(duì)側(cè)的肘關(guān)節(jié)腔內(nèi)解剖結(jié)構(gòu)是視野佳、入鏡容易、鏡子操作靈活的入路;特殊入路:經(jīng)后正中入路到鷹嘴窩,再使用磨鉆在鷹嘴窩建立一個(gè)大小約5~6mm的骨道,關(guān)節(jié)鏡經(jīng)骨道進(jìn)入冠突窩。70°關(guān)節(jié)鏡下可見(jiàn)肘關(guān)節(jié)腔內(nèi)的前關(guān)節(jié)囊、部分橈骨小頭、冠突、肱骨滑車(chē)、大部分肱橈關(guān)節(jié)面。30°關(guān)節(jié)鏡可見(jiàn)肘關(guān)節(jié)腔內(nèi)前關(guān)節(jié)囊、部分橈骨小頭、冠突、肱骨滑車(chē)。結(jié)論:(1)近端前內(nèi)側(cè)入路在肘關(guān)節(jié)屈曲(82.90±2.38)°時(shí)應(yīng)用70°關(guān)節(jié)鏡觀(guān)察肘關(guān)節(jié)腔內(nèi)是有效的內(nèi)側(cè)入路,推薦作為肘關(guān)節(jié)鏡手術(shù)的第一個(gè)入鏡點(diǎn)。(2)近端前外側(cè)入路在肘關(guān)節(jié)屈曲(82.90±4.46)°時(shí)應(yīng)用30°關(guān)節(jié)鏡觀(guān)察肘關(guān)節(jié)腔內(nèi)是有效的外側(cè)入路。(3)肘關(guān)節(jié)鏡單一入路均不能全面觀(guān)察整個(gè)肘關(guān)節(jié)腔,需建立多個(gè)聯(lián)合入路,如:后正中入路,近端前外側(cè)入路,中外側(cè)入路,近端前內(nèi)側(cè)入路。(4)特殊入路:經(jīng)后正中入路到鷹嘴窩,再使用磨鉆將鷹嘴窩打通進(jìn)入冠突窩;該入路安全有效,可用于尺神經(jīng)移位者或部分入路受限者。(5)總體來(lái)說(shuō)應(yīng)用70°關(guān)節(jié)鏡可更多探查有效的肘關(guān)節(jié)腔內(nèi)解剖,但要適當(dāng)旋轉(zhuǎn)屈曲全方位探索,可減少鏡下盲區(qū)便于了解腔內(nèi)解剖結(jié)構(gòu)。
[Abstract]:Objective: through the analysis of 30 degrees and 70 degrees of elbow arthroscopy arthroscopic anatomical view of different approach under the microscope, choose effective (the good view into the mirror, mirror easy, flexible operation) the optimum angle of elbow flexion, provide the anatomical basis for elbow arthroscopy in clinical application. Methods: (1) the thawing of frozen cadaveric elbows; (2) mark and fixed position: carefully touch surface anatomic landmark, lateral axis, and mark the upper arm and forearm of olecranon and medial epicondyle of humerus, lateral epicondylitis of the elbow position, the specimens were thawed is fixed on the bracket with prone position; (3) the establishment of approach: the required measurement approach by vernier caliper measurement and accurate marker of elbow arthroscopy (4); channel establishment: the lateral approach of elbow joint cavity injection of 20ml water expansion. The first one was cut into the skin in the proximal medial approach point About 3~4mm incision, separation of subcutaneous soft tissue and straight hemostatic forceps, and lumbar puncture to the center of the elbow puncture, water outflow pulled out after puncture puncture to the center of the elbow for lumbar puncture, finally with sheath puncture into the cavity and left elbow cone joint cavity, keep the puncture pull out the cone sheath after stabilization, the water flows out after 4.0mm were inserted into the 30 degrees and 70 degrees in the whole process of arthroscopy; saline suspension 3L bag about 3 meters high sustained pressure. Established by method of proximal anteromedial approach established through the anteromedial, anterolateral lateral approach, anterior lateral approach, proximal anterolateral lateral approach, posterior approach and posterolateral approach, then into the road to explore the new approach; (5) observation: through continuous buckling of elbow joint in 30 degrees and 70 degrees under arthroscopy to observe effective (the good view. Easily into the mirror, 闀滃瓙鎿嶄綔鐏墊椿)鏃舵祴閲忓叾鑲樺叧鑺傚眻鏇叉渶閫傝搴，

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