Siriraj Med J, Volume 58, Number 12, December 2006 1244
Special Issue
Arthroscopic Knee Surgery
„
Chanin Lamsam, M.D.
Department of Orthopaedics Surgery and Rehabilitation, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
Siriraj Med J 2006; 58: 1246-1248 E-journal: http://www.sirirajmedj.com
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∑”„Àâ欓∏‘ ¿“æ¿“¬„π¢âÕ‡¢à“À≈“¬™π‘¥ “¡“√∂∑”°“√ºà“μ—¥√—°…“
‰¥â‚¥¬«‘∏’„™â°≈àÕß·≈–Õÿª°√≥凧√◊ËÕß¡◊Õ´÷Ëß¡’≈—°…≥–‡©æ“–∑”„Àâ‡π◊ÈÕ
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¥â«¬ «‘∏’°“√„™â°≈âÕß Õ¥¡Õ߇¢â“‰ª„π¢âÕ‡ªìπ∑’Ëπ‘¬¡∑”°—πÕ¬à“ß·æ√à À≈“¬
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„™â°≈âÕߙ૬ ª√–°Õ∫‰ª¥â«¬¿“«–‡À≈à“π’È
- Synovitis - Loose body
- Patellofemotal joint instability - Foreign body - Discoid meniscus - Fat pad impingement - Meniscal tear - Degenerative joint
disease - Torn anterior cruciate ligament - Septic knee - Torn posterior cruciate ligament - Symptomatic plica - Chondral lesion - Painful total knee
replacement - Arthrofibrosis - Fractures
Arthoscopic knee procedures
°“√ºà“μ—¥¢âÕ‡¢à“‚¥¬°“√ Õ¥°≈âÕ߇¢â“‰ªμ√«®«‘π‘®©—¬‚¥¬∑—Ë«‰ª
·æ∑¬å®–°√’¥·º≈‡≈Á° Ê ª√–¡“≥ 0.5-1 ´¡. ∑’ˇ√’¬°«à“ portal ‡æ◊ËÕ
„™â‡ªìπ∑“ß ”À√—∫ Õ¥°≈âÕß·≈–‡§√◊ËÕß¡◊Õ‡¢â“‰ª„π¢âÕ‡¢à“ portal ∑’Ë
®–∑”‡ ¡Õ§◊Õ anteromedial parapatellar portal ·≈– anterolateral parapatellar portal ”À√—∫ portal Õ◊Ëπ Ê ·≈–·º≈ºà“μ—¥πÕ°‡Àπ◊Õ
‰ª®“°π’È¢÷ÈπÕ¬Ÿà°—∫·μà≈–≈—°…≥–¢Õß«‘∏’°“√ºà“μ—¥ ‡™àπ Õ“®®–¡’°“√
‰ªμ—¥‡π◊ÈÕ‡¬◊ËÕ∑’ËÕ◊Ëπ¡“‡æ◊ËÕ„™â∑” graft ∑’Ëπ‘¬¡§◊Õ§◊Õ bone patellar tendon bone graft, hamstring tendon graft, quadriceps tendon graft °“√
¥Ÿ·≈À≈—ߺà“μ—¥ºŸâªÉ«¬∫“ß°√≥’Õ“®∑”°“√‡§≈◊ËÕπ‰À«¢âÕ‰¥â‡≈¬¿“¬„π 24 ™—Ë«‚¡ßÀ≈—ߺà“μ—¥
Arthroscopic Removal of Loose bodies
‡ªìπ°“√„™â°≈âÕß¡ÕßÀ“™‘Èπ à«πÀ√◊Õ‡π◊ÈÕ‡¬◊ËÕ∑’ËÀ≈ÿ¥≈Õ¬Õ¬Ÿà„π¢âÕ
‡¢à“ ·≈–„™â‡§√◊ËÕß¡◊ÕÀ¬‘∫ÕÕ°¡“
Arthroscopic meniscal surgery
À¡Õπ√Õß°√–¥Ÿ°„π¢âÕ‡¢à“À√◊Õ meniscus ´÷Ëß©’°¢“¥ ®–∑”„Àâ ºŸâªÉ«¬‡®Á∫¢—¥„π¢âÕ‡«≈“‡§≈◊ËÕπ‰À« °“√ºà“μ—¥‡æ◊ËÕ‡¬Á∫´àÕ¡ (meniscal repair) À√◊Õμ—¥‡≈Á¡™‘Èπ à«π∑’Ë©’°¢“¥ (menisectomy) “¡“√∂∑”‰¥â
‚¥¬„™â°≈âÕß àÕߥŸ ·≈–„™â‡§√◊ËÕß¡◊Õ‡≈Á° Ê Õ¥‡¢â“‰ªμ—¥À√◊Õ‡¬Á∫
´÷Ëߢ÷ÈπÕ¬Ÿà°—∫≈—°…≥–°“√©’°¢“¥
Articular Cartilage Surgery
„π°√≥’´÷Ëß articular cartilage injury ∑”„À⺑«¢âÕ‰¡à‡√’¬∫ ¡’
°“√ºà“μ—¥∑” microfracture subchondral bone „πμ”·Àπàß´÷Ëß carti- lage π—Èπ∂Ÿ°∑”≈“¬®π∂÷ß™—Èπ subchondral bone ‚¥¬„™â‡§√◊ËÕß¡◊Õ‡¢â“‰ª μÕ°„Àâ subchondral bone ‡ªìπ√Ÿ¢π“¥ 2 mm. À≈“¬ Ê √Ÿ ‡æ◊ËÕ„Àâ
‡°‘¥ fibrocartilage ¢÷Èπ¡“§≈ÿ¡„π∫√‘‡«≥π—Èπ ·≈–∑”„À⺑«¢âÕ‡√’¬∫¢÷Èπ À√◊Õ°“√∑” obteochondral autologous plug transfer ´÷Ë߇ªìπ°“√
‰ª‡®“– osteochondral graft ¡“®“°∫√‘‡«≥¢âÕ‡¢à“´÷Ë߉¡àμâÕß√—∫πÈ”Àπ—°
¡“ ‡™àπ ∫√‘‡«≥„°≈â Ê ¢Õ∫πÕ°¥â“π∫π (superolateral part) ¢Õß lateral femoral condyle ¡“¬—ßμ”·Àπàß´÷Ëß¡’ cartilaginous defect
´÷ËßμâÕß√—∫πÈ”Àπ—°¡“°°«à“
Cruciate Ligaments Reconstruction
„πºŸâªÉ«¬´÷Ëß¡’°“√¢“¥¢Õß anterior ·≈–/À√◊Õ posterior cruci- ate ligament ·≈–¡’¢âÕ∫àß™’È„π°“√ºà“μ—¥ ligament reconstruction ªí®®ÿ∫—π “¡“√∂„™â arthroscopic techniques
Lateral Release and Medial Repair for Patellofemoral Joint Instability
„πºŸâªÉ«¬∑’Ë≈Ÿ° –∫â“À≈«¡¡’ subluxation À√◊Õ dislocation ¢Õß patellofemoral joint Õ“®·°â‰¢‰¥â¥â«¬°“√∑” lateral retinacalar release „π°√≥’´÷Ëß¡’ lateral tilting ¢Õß patellar À√◊Õ lateral reti- naculum —Èπ·≈–μ÷ß¡“°‡°‘π‰ª
Synovectomy
°“√ºà“μ—¥ arthroscopic synovectomy “¡“√∂∑”‰¥â¥’ ‚¥¬μ≈Õ¥
√Õ∫¢âÕ ∑—Èß∑“ß anterior ·≈– posterior compartment ‡™àπ„πºŸâªÉ«¬
pigmented villonudular, chronic synovitis ®“°¿“«–μà“ß Ê ‡™àπ rheumatoid arthritis, SLE ‡ªìπμâπ À√◊Õ‡ªìπ°“√∑”‡æ’¬ß synovial biopsy √à«¡°—∫ joint debridement ‡¡◊ËÕ¡’¿“«–¢âÕμ‘¥‡™◊ÈÕ
Arthroscopic Lysis Adhesion
¢âÕ‡¢à“´÷Ë߇§≈◊ËÕπ‰À«‰¥â®”°—¥ ‡π◊ËÕß®“°¡’æ—ߺ◊¥√—ÈßÕ¬Ÿà„π¢âÕ °“√
1245
μ‘¥æ—ߺ◊¥¥â«¬ arthroscope √à«¡°—∫°“√μ‘¥¢âÕ ®–∑”„Àâ¢âÕ‡¢à“‡§≈◊ËÕπ
‰À«‰¥â¡“°¢÷Èπ ·≈–°“√∑”°“¬¿“æ∫”∫—¥À≈—ߺà“μ—¥¥’ ‡æ√“–«à“‡π◊ÈÕ
‡¬◊ËÕ™Õ°™È”πâÕ¬
Arthroscopic Assisted Fracture Repair for Intra-articular Knee Fractures
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Tourniquet
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Arthroscopic knee surgery ‡ªìπ°“√ºà“μ—¥ ´÷Ëß„™â°≈âÕß Õ¥‡¢â“
‰ª„π¢âÕ‡¢à“∑”„Àâ¡Õ߇ÀÁπ欓∏‘ ¿“æμà“ß Ê „π¢âÕ‰¥âÕ¬à“ß™—¥‡®π
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- Artroscope
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·≈–‡≈π å´÷ËßÕ¬Ÿà„π∑àÕ‚≈À– arthroscope ∑’Ëπ‘¬¡„™âß“π„π°“√ºà“μ—¥
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∑”¡ÿ¡ 70 Õß»“ ”À√—∫ Õ¥·≈–¡Õ߉ª∑“ߥâ“πÀ≈—ߢÕߢâÕ„π∫“ß
§√—Èß „π¢≥–„™âß“π arthroscope ®–„ àÕ¬Ÿà„π canular sheath ´÷Ë߇ªìπ
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- Fiberoptic light source
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¡’§«“¡·√ß Ÿß¢π“¥ 300 «—μμå „À⧫“¡ «à“ß‚¥¬ àÕß· ߉ªμ“¡
‡§‡∫‘≈¢Õß “¬„¬·°â«π”· ß´÷ËßμàÕ‡¢â“‰ª„π°≈âÕß
- Television cameras
√–∫∫°≈âÕß‚∑√∑—»πå´÷ËßμàÕ‡¢â“°—∫ arthroscope ®–∂à“¬∑Õ¥¿“æ
„Àâª√“°Ø∫π®Õ´÷Ëß∑ÿ°§π„πÀâÕߺà“μ—¥®–¡Õ߇ÀÁπ‰¥â ·≈–¿“æ∑“ß
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·ºà𥑠°åÀ√◊Õ√Ÿª∂à“¬
- Probe
Probe ‡ª√’¬∫‡À¡◊Õππ‘È«¢Õß»—≈¬·æ∑¬å´÷Ëß Õ¥‡¢â“‰ª„π¢âÕ„™â
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‡ªìπ‡§√◊ËÕß¡◊Õ´÷Ëß„™â∑ÿ°§√—Èß probe ∑’Ë„™â arthroscopic knee surgery
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3-4 ¡.¡.
- Arthroscopic scissors
Antroscopic scissors ¡—°®–‡ âπºà“»Ÿπ¬å°≈“ߪ√–¡“≥ 3-4 ¡.¡.
·≈–∫√‘‡«≥ª≈“¬¡’√Ÿª·∫∫‰¥âÀ≈“¬≈—°…≥– ‡™à𠂧â߉ª∑“ߴ⓬
À√◊Õ¢«“‡æ◊ËÕ„À⇢⓰—∫≈—°…≥–μ”·ÀπàߢÕߢâÕ„π à«π∑’Ë¡’欓∏‘ ¿“æ
§¡°√√‰°√Õ“®¡’≈—°…≥–‚§âßßÕ‡À¡◊Õπμ–¢Õ‡æ◊ËÕ„Àâ‡π◊ÈÕ‡¬◊ËÕ∑’Ë®–μ—¥
‰¡à≈◊ËπÀ≈ÿ¥®“°°√√‰°√
Siriraj Med J, Volume 58, Number 12, December 2006 1246 - Basket forceps
basket forceps ‡ªìπ‡§√◊ËÕß¡◊Õ∑’Ë„™â¡“° ∫√‘‡«≥ à«πª≈“¬´÷Ëß„™â μ—¥‡π◊ÈÕ‡¬◊ËÕ®–¡’ª“°¥â“π∞“π‡ªìπ√Ÿ‡ªî¥ ‡æ◊ËÕ„Àâ‡π◊ÈÕ‡¬◊ËÕ∑’Ë∂Ÿ°μ—¥‰¡à§â“ß
§“Õ¬Ÿà„𪓰¢Õß forceps ∑”„Àâ‡π◊ÈÕ‡¬◊ËÕμàÕ‰ª‰¥â‚¥¬‰¡àμâÕߥ÷߇§√◊ËÕß
¡◊ÕÕÕ°¡“∑”§«“¡ –Õ“¥·≈– Õ¥‡¢â“‰ª„À¡à basket forceps ‰¥â
√—∫°“√ÕÕ°·∫∫¡“À≈“¬≈—°…≥–‡æ◊ËÕ„Àâ –¥«°„π°“√„™âß“π ∑—Èß
¢π“¥°â“π∑’Ë„À≠à‡≈Á°μà“ß°—π, ª≈“¬¥â“π∑”¡ÿ¡Õß»“¡“°πâÕ¬μà“ß°—π
·≈–≈—°…≥–ª≈“¬ª“°„À≠à‡≈Á°·≈–À—°‡ªìπ¡ÿ¡μà“ß Ê °—π
- Grasping forceps
Grasping forceps §◊Õ ‡§√◊ËÕß¡◊Õ„™âÀ¬‘∫®—∫‡π◊ÈÕ‡¬◊ËÕ„π¢âÕ¥÷ßÕÕ°¡“
‡™àπ loose bodies, meniscal tissue À√◊Õ cartilage à«πª≈“¬¢Õß grasping forceps ¡—°¡’≈—°…≥–‡ªìπ‡¢’È¬«À√◊Õøíπ‡≈◊ËÕ¬‡æ◊ËÕ„Àâ®—∫‡π◊ÈÕ
‡¬◊ËÕ‰¥â·πàπ
- Motorized shaving and bur systems
Motorized shaver ‡ªìπ‡§√◊ËÕß¡◊Õ´÷Ëß¡’≈—°…≥–æ◊Èπ∞“π‡ªìπ∑àÕ°≈«ß 2 ™—Èπ ∑”ß“π‚¥¬μàÕ‡§√◊ËÕß¡◊Õ°—∫ motor ·≈– suction ‚¥¬·√ߥŸ¥
®–¥÷߇π◊ÈÕ‡¬◊ËÕ¡“μ‘¥∑’Ë à«πª≈“¬¢Õß shaver ·≈– motor ®–À¡ÿπ∑àÕ
°≈«ß™—Èπ„π„À⧫߉ª¡“μ≈Õ¥‡«≈“∑”„Àâ‡π◊ÈÕ‡¬◊ËÕ∂Ÿ°μ—¥·≈–¥Ÿ¥ÕÕ°¡“
πÕ°¢âÕ shaver ‰¥â√—∫°“√ÕÕ°·∫∫„πÀ≈“¬≈—°…≥–¢÷ÈπÕ¬Ÿà°—∫‡π◊ÈÕ‡¬◊ËÕ
∑’Ë®–„™âμ—¥·≈–§«“¡§—∫·§∫¢Õß∫√‘‡«≥∑’Ë®–μ—¥
- Electrosurgical instruments
°≈ÿà¡ electrosurgical instruments ‡ªìπ‡§√◊ËÕß¡◊Õ´÷Ëß„™â°√–· ‰øøÑ“
‡ªìπμ—«∑”ß“π ¡’≈—°…≥–‡©æ“–∑’Ë ”§—≠§◊Õ à«πª≈“¬¢Õ߇§√◊ËÕß¡◊Õ π—Èπ “¡“√∂∑”ß“π‰¥â·¡â®–·™àÕ¬Ÿà„π lactated Ringerûs solution À√◊Õ normal saline μ≈Õ¥‡«≈“∑’Ë∑”ß“π ‡ªìπ‡§√◊ËÕß¡◊Õ„™â„π°“√Àâ“¡‡≈◊Õ¥
À√◊Õμ—¥‡π◊ÈÕ‡¬◊ËÕ
- ‡§√◊ËÕß¡◊Õ≈—°…≥–‡©æ“–
πÕ°®“°‡§√◊ËÕß¡◊Õæ◊Èπ∞“π‡À≈à“π’È·≈⫇§√◊ËÕß¡◊Õºà“μ—¥Õ◊Ëπ Ê ®–¢÷Èπ
°—∫≈—°…≥–°“√ºà“μ—¥ ‡™àπ music chondroplasty, anterior cruciate ligament reconstruction À√◊Õ meniscal repair ‡ªìπμâπ ®–μâÕß„™â
‡§√◊ËÕß¡◊Õ≈—°…≥–‡©æ“–¢÷Èπ°—∫·μà≈–«‘∏’°“√
Sterilization of Instruments
‡∑§π‘§°“√∑”„À⇧√◊ËÕß¡◊Õª≈Õ¥‡™◊ÈÕÕ“®‡≈◊Õ°∑”‰¥âÀ≈“¬«‘∏’ ‰¥â
·°à °“√π÷Ëß (steam autoclave), °“√Õ∫·°ä (Ethylene oxide gas sterilization) À√◊Õ°“√·™àπÈ”¬“ glutaraldehyde À√◊Õ peracetic acid
‡ªìπμâ𠇧√◊ËÕß¡◊ÕÕÿª°√≥å´÷Ë߉¡àÕ“®∑𧫓¡√âÕπ Ÿß‰¥â°“√π÷Ëß®–∑”„Àâ
‡°‘¥§«“¡‡ ’¬À“¬ ‰¥â·°à arthroscope, °≈âÕß‚∑√∑—»πå, “¬‡§‡∫‘≈
„¬·°â«πÈ”· ß μâÕß„™â«‘∏’Õ∫·°ä À√◊Õ·™àπÈ”¬“ à«π‡§√◊ËÕß¡◊Õ ‡™àπ ¡’¥, graspers, basket forceps ·≈– canular §«√„™â«‘∏’π÷Ëß
Irrigation Systems
°“√∑”ºà“μ—¥¥â«¬ arthroscope ·æ∑¬å®–„™â normal saline À√◊Õ lactated Ringerûs solution „ à‡¢â“‰ª„π¢âÕ ‡æ◊ËÕÀ«—ߺ≈„π°“√™”√–
≈â“߇»…‡π◊ÈÕ‡¬◊ËÕ·≈–‡≈◊Õ¥´÷Ëß®–∫¥∫—ß¿“æ ·≈–∑’Ë ”§—≠§◊Õ ‡æ◊ËÕ¢¬“¬
™àÕß«à“ß¿“¬„π¢âÕ‚¥¬°“√‡æ‘Ë¡·√ߥ—π¿“¬„π¢âÕ ∑”„À⇬◊ËÕÀÿâ¡¢âÕ·≈–
capsule ∂Ÿ°¥—π¢¬“¬∂à“ßÕÕ° ∑”„Àâ¡Õ߇ÀÁπ‚§√ß √â“ß¿“¬„π¢âÕ‰¥â
™—¥‡®π©–π—Èπ„π√–∫∫ irrigation ®–ª√–°Õ∫‰ª¥â«¬∑“ßπÈ”‡¢â“·≈–
∑“ß√–∫“¬ÕÕ°´÷ËßÕ“®„™â∑àÕ·¬°μà“ßÀ“°À√◊Õºà“π∑“ß artroscopic sheath °Á‰¥â ªí®®ÿ∫—π‡√“Õ“®‡≈◊Õ°„™â«‘∏’√–∫“¬πÈ”‡¢â“‰ª‰ª„π¢âÕ‚¥¬
„™â‡§√◊ËÕߪíô¡ ´÷Ëß “¡“√∂§«∫§ÿ¡·√ߥ—π·≈–Õ—μ√“°“√‰À≈¢ÕßπÈ”‰¥â Õ¬à“ߥ’ À√◊Õ„™â«‘∏’∑’Ëßà“¬·≈–ª√–À¬—¥°«à“‚¥¬„™â∂—ß·¢«π‰«â°—∫‡ “ „Àâ
∂—ßÕ¬Ÿà„πμ”·Àπàß Ÿß°«à“¢âÕ 3-4 øÿμ √–¥—∫∂—ßπÈ”∑’Ë Ÿß°«à“¢âÕ 1 øÿμ
‡∑à“°—∫·√ߥ—π 22 ¡¡.ª√Õ∑ ‡¡◊ËÕμâÕß°“√·√ߥ—π∑’Ë Ÿß‡æ‘Ë¡¢÷Èπ°Á„™â
°“√¬°√–¥—∫∂—ß„À⠟ߢ÷Èπ
¿“«–·∑√°´âÕπ
¿“«–·∑√°´âÕπÕ—π‡π◊ËÕß¡“°®“° arthroscope æ∫‰¥âπâÕ¬¡“°
Õ—μ√“°“√‡°‘¥¿“«–·∑√°´âÕπμË”°«à“ 1% ´÷Ëß à«π„À≠à‡°‘¥®“°¡’°“√
∫“¥‡®Á∫‡≈Á°πâÕ¬ μàÕ articular cartilage, cutaneous renue ·≈–À≈Õ¥
‡≈◊Õ¥¥”®“°°“√ Õ¥‡§√◊ËÕß¡◊Õ‡¢â“‰ª‚¥¬¢“¥§«“¡√–¡—¥√–«—ß¿“«–
°“√μ‘¥‡™◊ÈÕ·∑√°´âÕπÀ≈—ߺà“μ—¥„π¢âÕ‡¢à“À√◊Õ∫√‘‡«≥·º≈ºà“μ—¥æ∫
πâÕ¬¡“°
·μຟâªÉ«¬¬—ߧߡ’‚Õ°“ ‡°‘¥¿“«–·∑√°´âÕπÕ◊Ëπ Ê Õ—π‡π◊ËÕß¡“®“°
«‘∏’°“√√–ß—∫§«“¡√Ÿâ ÷°·≈–ºà“μ—¥∫√‘‡«≥‡¢à“‰¥â‡™àπ°—𠇙àπ ªí “«–
‰¡àÕÕ°À≈—ߺà“μ—¥, deep vein thrombosis, ¿“«–·∑√°´âÕπ®“°°“√
«“ß graft ‰¡à∂Ÿ°μ”·Àπàß„π ligament reconstruction ‡ªìπμâπ
