医学关节镜下打结技术培训 培训ppt课件

关节镜下打结技术关节镜下打结技术关节镜下打结技术1An 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 tearsMany are also performing capsular shifts to treat instability.Essential to these procedures is the ability to tie arthroscopic knots to approximate intraarticularIntroductionAn increasing number of surgeo2The surgeon must sequentially construct the knot outside the joint and then pass the knot into the joint through small cannulasTying arthroscopic knots is technically demanding and requires considerable practiceWith the popularity of arthroscopic surgery,the number of used arthroscopic knots and the number of surgeons using these knots has increasedThe surgeon must sequentially 3Knot Tying PrinciplesThe goal of knot tying is to approximate tissue 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 failureKnot Tying PrinciplesThe goal 4Knot security friction,internal interference,and slack between throws Friction is inherent to the suture materialInternal interference the configuration of the knot and increased by the length of the contact between the loop limb and the post limbslack between the individual throws in each knot to maximize loop securityslippage can lead to failure of tissue appositionKnot Tying PrinciplesKnot security friction,inter5ufour different processes of knot failure knot slippage and looseningsuture breakagetissue failuresuture anchor pullout from bonethrough suture breakageKnot failure four different processes of kn6Knot Terminologypost 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)Knot Terminologypost limb(als7FIGURE 1.Loop and post configuration FIGURE 1.Loop and post config8Arthroscopic Knot PushersAn 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 Arthroscopic Knot PushersAn ar9FIGURE 3.Mitek knot pushers.A.Single-hole,B.Double-hole,C.Slotted FIGURE 3.Mitek knot pushers.10double-hole knot pushers and double diameter knotdouble-hole knot pushers and double diameter knot pushers like the Arthrex 6th Finger(Arthrex,Naples,FL).Double-diameter knot pushers provide better loop security compared to standard single-hole knot pushersdouble-hole knot pushers and d11Double-hole knot pusherFIGURE 4.Double-hole knot pusher.Double-hole knot pusherFIGURE 12How to Use the Double-Diameter Knot Pusher FIGURE 5.A-F.Tying knots with the Arthrex 6th finger How to Use the Double-Diameter13Suture PropertiesTwo 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,polyester,nonabsorbable sutures are Ethibond and Ticron Examples of absorbable,monofilament sutures are PDS II,polydiaxonone and Maxon,polyglyconate Suture PropertiesTwo types of 14Braided polyester has increased pliability,ductility,a higher coefficient of friction and greater strength 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 with excessive handling,which may lead to suture ruptureBraided polyester has increase15uBraided polyester suture may be coated to:improve surgeon handling reduce friction between the suture and surrounding tissue,which can lead the tissue damagedecrease friction between suture limbs,which may lead to frayingHowever,suture coating decreases the coefficient of friction of the knot,which theoretically increases the risk of knot slippageBraided polyester suture may b16Knots tied with absorbable,monofilament sutures are easier to slide down a post and do not frayThere is less friction between the suture and surrounding tissue leading to less potential tissue damage when the suture is pulled through the tissueabsorbable sutures dissolve and do not leave knots that may cause a persistent inflammatory reaction after tissue healing Absorbable sutures can appose tissue under stress for approximately six weeks with complete absorption occurring in approximately six months Knots tied with absorbable,mo17However,absorbable monofilament sutures are harder to handle than polyester making it more difficult to keep knots tight and secure Also,a 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 However,absorbable monofilame18The size of the suture is also a factor in determining a knots holding capacity and also the tensile strength of the suture itselfClinical 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.The size of the suture is also19Knot TypesThere 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 fails at higher loads than do series of half hitches in hand-tied knots(38),the square knot is not commonly used arthroscopically.Knot TypesThere are a variety 20The square knot is a flat knot in which both strands enter and leave the knot parallel to each other(Fig.6).In order to tie a square knot,symmetric tension must be simultaneously applied to each limb,which is difficult to do arthroscopicallyIf asymmetric tension is applied to one of the limbs,the knot converts to two nonidentical half hitchesThus,most arthroscopic surgeons prefer using a series of half hitchesThe square knot is a flat knot21FIGURE 6.Square knot configuration.FIGURE 6.Square knot configur22Sliding 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 tied 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.Some sliding knots preferentially slide in only one directionSliding knots,like the Duncan23A 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 knots)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 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)A locking knot is a modificati24Locking and 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 locking 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.When 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.Locking and sliding knots can 25Knot Pushing and PullingKnot 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 behind the knot thus pushing the loop over the post limb into the joint(Fig.7B).Knot Pushing and PullingKnot c26FIGURE 7.A.Knot pulling,B.Knot pushing.FIGURE 7.A.Knot pulling,B.27Tying Half HitchesUsing the one hand knot-tying technique,half hitches can be tied either underhand or overhand The following instructions define an underhand loop and an overhand loopTying Half HitchesUsing the on28FIGURE 8.A-E.Underhand half hitch.FIGURE 8.A-E.Underhand half 29医学关节镜下打结技术培训 培训ppt课件30Configuration of Half HitchesHalf 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.Configuration of Half HitchesH31Post SwitchingFIGURE 13.A.Parallel loop and post limbs.B.Parallel loop and post limbs with a“flat”knot.Post SwitchingFIGURE 13.A.Pa32FIGURE 14.A.Twisted loop and post limbs.B.When tying a knot with twisted post and loop limbs,the knot does not lie“flat.”C.The final knot configuration will loosen if the knot is tied when the loop and post limbs are twisted.FIGURE 14.A.Twisted loop and33Chan and Burkhart described a may increase the speed of the knot-tying process and also help limit twisting of the suture limbs.One can“flip”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,but it can also be done with braided suture.Chan and Burkhart described a 34Hold 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 converting 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).Hold the post in the nondomina35Post Switching Technique FIGURE 15.A-C.Post switching technique Post Switching Technique FIGUR36Arthroscopic 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 sutures 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 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 tyingArthroscopic Knot-Tying Techni37The 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-hole 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 the 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 hitchThe arthroscopic surgeon shoul38Non-Sliding KnotsFIGURE 16.A-F.Square knot.Non-Sliding KnotsFIGURE 16.A-39Revo 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 FIGURE 17.A-H.Original Revo knot.Revo Knot The Revo knot is a s40The 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 the 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.17D).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 pusher,and past-point to cinch the knot down.(Fig.17H)The Original Revo knot consist41Snyders Knot Snyders Knot 42医学关节镜下打结技术培训 培训ppt课件43Snyders Knot Snyders Knot 44Snyders is another variation of the Revo knot Throw an overhand loop around the post(Fig.18A).Pull the loop into the joint with the knot pusher on the loop limb(Fig.18B)Withdraw the knot pusher while maintaining tension on the post limb.Throw an underhand loop around the same post(Fig.18C)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.18D).Switch posts and throw an overhand loop around the new post(Fig.18E).Pull the loop into the joint,seat the knot with the knot pusher,and past-point to cinch the knot down(Fig.18F).Next,throw an underhand loop around the post(Fig.18G).Pull the loop into the joint,seat the knot with the knot pusher,and past-point to cinch the knot down(Fig.18H).Switch posts and throw an overhand loop around the new post(Fig.18I).Pull the loop into the joint,seat the knot with the knot pusher,and past point to cinch the knot down(Fig.18J).Snyders is another variation 45FIGURE 19.A-K.Revo knot.FIGURE 19.A-K.Revo knot.46医学关节镜下打结技术培训 培训ppt课件47The current Revo knot is a modification of the Original Revo knotThrow an underhand loop around the post(Fig.19A).Advance the loop with the knot pusher on the loop limb until the first half hitch is seated(Fig.19B).Withdraw the knot pusher while maintaining tension on the post limb.Throw another underhand loop around the same post(Fig.19C).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(Figs.19D,E).Throw an overhand half hitch around the post and advance with the knot pusher(Fig.19F).Further tension by past pointing and apply tension on both limbs while holding the (Fig.19G).Switch posts and throw an underhand loop around the new post(Fig.19H).Pull the loop into the joint,seat the knot with the knot pusher,and past point to cinch the knot down(Fig.19I).Switch posts and throw an overhand loop around the new post(Fig.19J).Pull the loop into the joint,seat the knot with the knot pusher,and past point to cinch the knot down(Fig.19K).The current Revo knot is a mod48Sliding KnotsOverhand Throw Sliding KnotsOverhand Throw 49Duncan Loop The Duncan loop was originally described in the fishing literature(Uni-Knot)and has been modified for use in arthroscopic surgery.The arthroscopic Duncan loop is also known as the Fishermans knot or the Hangmans knot The difference between the fishing knot and the arthroscopic knot is the direction the loop strand travels around the post.When tying the fishing Duncan loop,one wraps the loop limb around the post in a direction away from the joint.To tie the modified Duncan loop or Hangmans knot,the surgeon sequentially wraps the loop limb around the post in a direction toward the jointDuncan Loop The Duncan loop 50FIGURE 21.A-F.Fishing Duncan loop.FIGURE 21.A-F.Fishing Duncan51医学关节镜下打结技术培训 培训ppt课件52Berkley Duncan Loop KnotBerkley Duncan Loop Knot53Arthroscopic Duncan Loop(Hangmans Knot)(Fig.22)FIGURE 22.A-F.Arthroscopic Duncan loop.Arthroscopic Duncan Loop(Hang54French knot.FIGURE 23.A-H.FIGURE 23.A-H.French knot.French knot.FIGURE 23.A-H.F55医学关节镜下打结技术培训 培训ppt课件56医学关节镜下打结技术培训 培训ppt课件57医学关节镜下打结技术培训 培训ppt课件58The French knot(22)is a sliding knot that is a modification of the Duncan loop.Make the post limb half as long as the loop limb.Grasp the sutures between the thumb and index finger of your non-dominant hand(Fig.23A).Create a small circle in the loop strand by passing the loop over the combined post and loop strands and hold it between your thumb and index finger(Fig.23B).Make a total of four loops around both the post and the loop limbs traveling toward the joint(Fig.23C).Pass the tail of the loop strand over and through the small circle in the loop strand that is held between the thumb and index finger(Fig.23D).Pass the tail of the loop strand under and through the loop circle created by the distal end of the loop strand and the combined limbs of the loop and post strands(Fig.23E).Pull on both the loop limb and the post limb symmetrically to tighten the knot(Fig.23F).Advance the knot by pulling on the post limb while pushing the knot down with the knot pusher on the post strand(Fig.23G).Lock the knot with a series of three alternating half hitches with post switching(Fig.23H).Throw an underhand loop on the original post.Tension with the knot pusher.Switch posts.Throw an overhand loop over the new post.Tension with the knot pusher.Switch posts.Throw an underhand loop on the original post again.Tension with the knot pusher.The French knot was shown to have a higher load to failure when compared to the Duncan loop and the Revo knot The French knot(22)is a slid59Roeder Knot The Roeder knot is a sliding knot that is a variation of the Duncan loop.It was originally used in tonsillectomy surgery and described in the German literature by Rder in 1918There have been several modifications of the knot that have been described since the initial description of the knot.Modifications of the Roeder knot are currently used in both laparoscopic and arthroscopic surgeryRoeder Knot The Roeder knot is60FIGURE 24.A-G.Roeder knot.FIGURE 24.A-G.Roeder knot.61The post limb should be one half the length of the loop limb.Throw the first loop around the post limb and then hold the loop and post together with the thumb and index finger of the non-dominant hand(Fig.24A).Throw a second loop around both the post and loop limbs(Fig.24B).Throw a third loop around only the post limb and between the post and loop(Fig.24C).Pass the tail of the loop between the second and third turns and in between the loop limb and the post limb(Fig.24D).Tension the knot by gently pulling on both the post and the loop limbs simultaneously(Fig.24E).While pulling on the post limb,push the knot into the joint with the knot pusher on the post s