关节镜下打结技术培训课件.ppt

1、本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。An increasing number of surgeons are performing arthroscopic surgery in the knee to repair meniscal tears and in the shoulder to repair rotator cuff or labral tears Many are also performing capsular shifts to treat instability.Essential to these proced

2、ures is the ability to tie arthroscopic knots to approximate intraarticularIntroduction本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。The surgeon must sequentially construct the knot outside the joint and then pass the knot into the joint through small cannulas Tying arthroscopic knots is technical

3、ly demanding and requires considerable practice With the popularity of arthroscopic surgery,the number of used arthroscopic knots and the number of surgeons using these knots has increased本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Knot Tying Principles The goal of knot tying is to approximate t

4、issue under tension and maintain the tissue in apposition until biologic repair and healing can occur It is imperative for all surgeons to learn and use knot-tying techniques that minimize the chance of knot failure本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Knot security friction,internal inter

5、ference,and slack between throws Friction is inherent to the suture material Internal interference the configuration of the knot and increased by the length of the contact between the loop limb and the post limb slack between the individual throws in each knot to maximize loop security slippage can

6、lead to failure of tissue appositionKnot Tying Principles本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。ufour different processes of knot failure knot slippage and looseningsuture breakagetissue failuresuture anchor pullout from bonethrough suture breakageKnot failure 本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；

7、如有不当之处，请联系网站或本人删除。Knot Terminology post limb(also commonly known as the axial limb)loop limb(also commonly known as the wrapping limb,working end,running end,or free end)Knots are constructed by tying the loop limb around the post limb(Fig.1)本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。FIGURE 1.L

8、oop and post configuration 本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Arthroscopic Knot Pushers An arthroscopic knot pusher is a device used to advance the loop down the post limb into the joint to create the knot.Arthrex knot pushers.A.Single-hole,B.Double-hole,C.6th Finger 本文档所提供的信息仅供参考之用，不能作

9、为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。FIGURE 3.Mitek knot pushers.A.Single-hole,B.Double-hole,C.Slotted 本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。double-hole knot pushers and double diameter knot double-hole knot pushers and double diameter knot pushers like the Arthrex 6th Finger(Arthrex,Naples,FL).Do

10、uble-diameter knot pushers provide better loop security compared to standard single-hole knot pushers本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Double-hole knot pusherFIGURE 4.Double-hole knot pusher.本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。How to Use the Double-Diameter Knot Pusher FIGU

11、RE 5.A-F.Tying knots with the Arthrex 6th finger 本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Suture Properties Two types of sutures are commonly used in tying arthroscopic knots:a permanent,braided,polyester,nonabsorbable suture and an absorbable,monofilament suture Examples of permanent,braided

12、,polyester,nonabsorbable sutures are Ethibond and Ticron Examples of absorbable,monofilament sutures are PDS II,polydiaxonone and Maxon,polyglyconate 本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Braided polyester has increased pliability,ductility,a higher coefficient of friction and greater stre

13、ngth than does absorbable monofilament Because the braided suture is more pliable,the volume of the knot is decreased and these knots can be cinched tighter.Knots tied with Ethibond were shown to be stronger when compared to PDS II in several biomechanical studies However,braided polyester may fray

14、with excessive handling,which may lead to suture rupture本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。uBraided polyester suture may be coated to:improve surgeon handling reduce friction between the suture and surrounding tissue,which can lead the tissue damage decrease friction between suture limb

15、s,which may lead to fraying However,suture coating decreases the coefficient of friction of the knot,which theoretically increases the risk of knot slippage本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Knots tied with absorbable,monofilament sutures are easier to slide down a post and do not fray

16、There is less friction between the suture and surrounding tissue leading to less potential tissue damage when the suture is pulled through the tissue absorbable sutures dissolve and do not leave knots that may cause a persistent inflammatory reaction after tissue healing Absorbable sutures can appos

17、e tissue under stress for approximately six weeks with complete absorption occurring in approximately six months 本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。However,absorbable monofilament sutures are harder to handle than polyester making it more difficult to keep knots tight and secure Also,a

18、absorbable monofilament suture will fail earlier with cyclic loading than polyester suture and may expand by plastic deformation more than 30%of its length before breaking 本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。The size of the suture is also a factor in determining a knots holding capacity

19、and also the tensile strength of the suture itself Clinical failure of all knots and suture types improved by 100%when suture size was increased by 2 gauges USP(U.S.Pharmacopeia.The size suture most commonly used in arthroscopic surgery is No.1 or No.2.本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除

20、。Knot Types There are a variety of knot include nonsliding knots,sliding knots,and locking knots.Nonsliding knots are knots that do not slide though the tissues being apposed.They include the square knot and knots consisting of a series of half hitches like the Revo knot(34)Although the square knot

21、fails at higher loads than do series of half hitches in hand-tied knots(38),the square knot is not commonly used arthroscopically.本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。The square knot is a flat knot in which both strands enter and leave the knot parallel to each other(Fig.6).In order to ti

22、e a square knot,symmetric tension must be simultaneously applied to each limb,which is difficult to do arthroscopically If asymmetric tension is applied to one of the limbs,the knot converts to two nonidentical half hitches Thus,most arthroscopic surgeons prefer using a series of half hitches本文档所提供的

23、信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。FIGURE 6.Square knot configuration.本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Sliding knots,like the Duncan loop(27),are useful in opposing tissue under tension.While tying a sliding knot,the post strand is held under tension while the loop strand is tie

24、d around it.Because the post strand is not incorporated into the structure of the knot,the knot,once tied,can easily move down the post resulting in a sliding knot instead of a flat knot such as the square knot.Once the sliding knots are seated,they are often locked with a series of half hitches.Som

25、e sliding knots preferentially slide in only one direction本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。A locking knot is a modification of a sliding knot A simple sliding knot can loosen before a series of half hitches are thrown to“lock”the sliding knot in placelocking knots(also known as flip k

26、nots)have been developed to maintain initial loop security that does not loosen when tension is removedThe post strand“flips,”converting the loop strand into the new post strand and locking the knot into place.An example of a locking knot is the SMC knot.locking knots do not need to be supplemented

27、with a series of half hitchesThe authors of this manual have found locking knots without reinforcing half hitches to be inferior in tensile strength to knots reinforced with three reversed half hitches on alternating posts(unpublished data)本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Locking and

28、sliding knots can be advanced into the joint just by pulling on the post.This can cause tension at the repair site,which can damage the tissue being apposed.Tension at the repair site can be minimized by pushing the knot ahead with the knot pusher while simultaneously pulling on the post limb.With l

29、ocking and sliding knots,it is important that the loop limb is at least twice as long as the post limb.If it is not,when pulling the post limb to advance the knot through the cannula and into the joint,the shortened loop limb may be pulled into the cannula making it impossible to secure the knot.Whe

30、n using a sliding or locking knot configuration,it is important to ensure that the suture slides easily through the tissue being opposed.If the suture does not slide easily,the surgeon should consider using a nonsliding knot.本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Knot Pushing and Pulling Kn

31、ot configurations can be either pushed or pulled into the joint.he arthroscopic knot-tying device is positioned on the loop limb and is advanced past the half hitch thus pulling the loop over the post limb into the joint(Fig.7A).The arthroscopic knot-tying device is positioned on the post limb behin

32、d the knot thus pushing the loop over the post limb into the joint(Fig.7B).本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。FIGURE 7.A.Knot pulling,B.Knot pushing.本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Tying Half Hitches Using the one hand knot-tying technique,half hitches can be tied either

33、 underhand or overhand The following instructions define an underhand loop and an overhand loop本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。FIGURE 8.A-E.Underhand half hitch.本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Configuration of Half Hitch

34、es Half hitches can be thrown in the same direction(two successive overhand hitches)or can be thrown in opposite directions(an overhand hitch followed by an underhand hitch)Half hitches can also be tied on opposite posts.Tera and Aberg(37)developed a nomenclature for describing flat knots.本文档所提供的信息仅

35、供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Post SwitchingFIGURE 13.A.Parallel loop and post limbs.B.Parallel loop and post limbs with a“flat”knot.本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。FIGURE 14.A.Twisted loop and post limbs.B.When tying a knot with twisted post and loop limbs,the knot does not

36、lie“flat.”C.The final knot configuration will loosen if the knot is tied when the loop and post limbs are twisted.本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Chan and Burkhart described a may increase the speed of the knot-tying process and also help limit twisting of the suture limbs.One can“fl

37、ip”a half hitch by releasing tension on the post limb and pulling on the loop limb.When the post is switched,the direction of the half hitch is also reversed.The authors of this technique report that it is easier to flip half hitches using monofilament because it more readily converts to a flat knot

38、,but it can also be done with braided suture.本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Hold the post in the nondominant hand and the loop in the dominant hand(Fig.15A).Move the original post forward and ahead of the half hitch.Apply parallel traction on the post and loop simultaneously convert

39、ing the half hitch to a flat knot(Fig.15B).Apply axial traction to the loop limb converting it into the new post limb and the half hitch is reversed(Fig.15C).本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Post Switching Technique FIGURE 15.A-C.Post switching technique 本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；

40、如有不当之处，请联系网站或本人删除。Arthroscopic Knot-Tying TechniquesIt is important to determine if the suture slides through the tissue and suture anchor prior to knot tying.If the suture does not readily slide,a sliding or locking knot should not be used and a nonsliding knot should be chosenOnly one pair of sutu

41、res should be within the working cannula during arthroscopic knot tying.If more than one pair of sutures are within the working cannula during tying,there is a high likelihood that the sutures will become twisted and knot tying will become quite tedious if not impossible.Additional sutures should be

42、 shuttled via a monofilament suture(less tissue abrasion)or by an arthroscopic grasper to an accessory portalTransparent cannulas are recommended for arthroscopic knot tying.These cannulas allow the surgeon to see if there is any twisting of the suture strands prior to knot tying本文档所提供的信息仅供参考之用，不能作为

43、科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。The arthroscopic surgeon should ensure that there is no redundant soft tissue around the tissue being apposed or in the path of the suture limbs because this will impede knot tying and increase the likelihood of knot failureWhen tying half hitches with a standard single-h

44、ole knot pusher,the first throw commonly slips when the knot pusher is removed in preparation for the second throw When the second throw is advanced,there is a chance that the hitches will lock prior to complete apposition of the tissueTo prevent this,the surgeon can throw the first two hitches in t

45、he same direction allowing the hitches to slide down the post to appose the tissue Another method of preventing initial loop loosening is to use a double-diameter knot-pushing device,such as the Arthrex 6th to maintain tension on the initial hitch while throwing the second hitch本文档所提供的信息仅供参考之用，不能作为科

46、学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Non-Sliding KnotsFIGURE 16.A-F.Square knot.本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Revo Knot The Revo knot is a series of multiple half hitches made by alternating the post and direction of the half hitches.There have been several modifications to the Revo knot FIG

47、URE 17.A-H.Original Revo knot.本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。The Original Revo knot consists of two reversed half hitches on an identical post followed by post switching and two reversed half hitches.Throw an overhand loop around the post(Fig.17A).Pull the loop into the joint with t

48、he knot pusher on the loop limb(Fig.17B)Withdraw the knot pusher while maintaining tension on the post limb.Throw an underhand loop around the same post(Fig.17C)Pull the loop into the joint and seat the knot with the knot pusher.Once the two hitches are seated,past-point to cinch the knot down(Fig.1

49、7D).Switch posts and throw an underhand loop around the new post(Fig.17E).Pull the loop into the joint,seat the knot with the knot pusher,and past-point to cinch the knot down(Fig.17F).Next,throw an overhand loop around the post(Fig.17G).Pull the loop into the joint,seat the knot with the knot pushe

50、r,and past-point to cinch the knot down.(Fig.17H)本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Snyders Knot 本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Snyders Knot 本文档所提供的信息仅供参考之用，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Snyders is another variation of t