膝关节滑膜相关结构的解剖与影像学观测及临床应用研究

发布时间：2018-04-20 16:03

本文选题：膝关节 + 滑膜形态　；参考：《重庆医科大学》2011年硕士论文

【摘要】：目的:滑膜异常、关节积液是膝关节的常见病变。但由于膝关节结构的复杂性,滑膜异常、关节积液表现不一,给临床诊治带来困难。本课题拟通过膝关节各部滑膜的解剖,探究滑膜囊形成的解剖学基础,寻找患者膝关节病变的滑膜变化特征;通过对新鲜成人尸体正常膝关节腔内注入不同量对比剂的标本进行MRI观察,为临床确诊膝关节腔及周围滑膜囊内不同量积液提供客观依据和定量标准。方法: (1)标本铸型成人新鲜尸体下肢标本20侧,经股动脉注入红色乳胶悬浮液;在关节腔和髌下深囊内注入1:1牙托粉和牙托水混合液。填充剂凝固后,放入30%的盐酸液中腐蚀,制作成下肢铸型标本。 (2)形态学观察对30侧膝关节标本进行解剖,肉眼观察髌上囊、髌下深囊、髌软骨、后内侧隐窝处滑膜的形态及髌下深囊与关节腔间组织结构;并于上述部位取材,行组织学观察。 (3)标本、活体测量测量20侧膝关节标本在屈、伸位时,髌下深囊的形态变化;对20例自愿者髌骨下缘和胫骨粗隆体表定位,测量其膝关节在屈、伸运动时,髌韧带连于髌骨下缘和胫骨粗隆的长度。 (4)积液的定量对10件无积液、积气、结构正常的成人尸体膝关节腔内依次注入1、5、10、15、20、30、40ml对比剂,分别于每次注射后行冠状面、矢状面、横断面T2WI,厚度4 mm,间距1 mm,MRI扫描。结果: 髌下深囊特点:髌下深囊与关节腔有相同的滑膜组织,但彼此间并非延续而成,二者之间被髌下脂肪组织填充分隔;关节腔、髌下深囊及其之间区域主要通过膝降动脉、膝下内侧动脉和膝上、下外侧动脉及其分支连通。膝关节标本伸位时,髌下深囊长0.9cm～1.1cm,最宽处0.5cm,高0.3cm～0.5cm,髌韧带长度4.5cm～4.8cm;膝关节标本屈位(45°)时,髌下深囊长0.8～1.0cm,最宽处0.6cm,高0.4cm～0.6cm。活体测量髌骨下缘与胫骨粗隆的距离,伸位时4.5cm～4.8cm,屈位时(145°)9.0cm～9.5cm。滑膜形态学特点:髌软骨上缘处滑膜质地变硬发生率为87%(26/30)、髌上囊内滑膜厚度大于5mm发生率为73%(22/30)、髌下深囊内滑膜表面粗糙发生率为70%(21/30),与其他部位比较差异均有显著性意义(p0.001)。髌软骨上缘、后内侧隐窝处滑膜细胞及小血管增生发生率分别为80%(24/30)和57%(17/30)、间质纤维化及玻璃样变发生率分别为83%(25/30)和74%(22/30),与其他部位比较差异均有显著性意义(P0.001)。积液定量测定:①在膝关节冠状面MRI扫描:注入10 ml对比剂时,经膝关节内侧中点处,关节腔内均可见高信号。②在膝关节正中矢状层面内侧1.5 cm处MRI扫描:5 ml对比剂时,高信号区呈前粗后细达髁间隆起前缘,70%胫骨内侧髁后上方可见高信号区。③在膝关节横断面经髌骨尖下缘处MRI扫描:对比剂5 ml时,90%关节腔后1/3段可见高信号;对比剂10 ml,70%股骨前缘平面出现高信号区。结论:髌下深囊与关节腔滑膜不延续,髌韧带摩擦是其滑膜形成的原因之一。髌下深囊、髌上囊、髌软骨上缘处滑膜易发生大体形态学改变,后内侧隐窝和髌软骨上缘处滑膜是组织学改变最显著的部位。通过对膝关节腔及周围滑膜囊注入不同量对比剂,建立不同量积液的参照标准,对MRI诊断膝关节腔及周围滑膜囊积液具有重要价值。
[Abstract]:Objective: synovial abnormalities, joint effusion is a common lesion of the knee joint. However, due to the complexity of the knee joint structure, abnormal synovial membrane and joint effusion, it is difficult to diagnose and treat the clinical diagnosis and treatment. MRI observation was carried out on specimens of normal knee joint of fresh adult cadavers by injecting different contrast agents to provide objective and quantitative criteria for the clinical diagnosis of different amount of fluid in the knee joint cavity and the surrounding synovial capsule.
Method:
(1) 20 sides of the specimens of fresh cadaver specimens of adult cadavers were injected into the femoral artery and injected with red latex suspension; the 1:1 denture powder and denture water mixture were injected into the joint cavity and the deep patellar capsule. After the filling agent was solidified, 30% hydrochloric acid was put into the fluid and made into a lower limb cast specimen.
(2) morphological observation of the 30 sides of the knee joint specimens, the naked eye observed the upper patellar capsule, the deep capsule of the patellar, the patellar cartilage, the posterior medial recess, the morphology of the synovium in the posterior medial recess and the tissue structure between the deep capsule and the articular cavity.
(3) specimen, measuring and measuring the morphological changes of the deep Subpatellar bursa in the flexion and extension of the 20 sides of the knee joint, and the location of the lower patellar and tibial tuberosity in 20 volunteers, and measuring the length of the patellar ligament at the lower margin of the patella and the tibial tuberosity when the knee joint was flexed and extended.
(4) 1,5,10,15,20,30,40ml contrast agent was injected into the knee joint of 10 pieces of adult cadavers without fluid accumulation, gas accumulation and normal structure. After each injection, the coronal surface, sagittal plane, cross section T2WI, thickness 4 mm, distance 1 mm, MRI scan were performed after each injection.
Result:
The characteristics of the deep Subpatellar capsule: the Subpatellar deep capsule and the articular cavity have the same synovial tissue, but they are not continuous. The two are filled with the subpatellar fat tissue; the joint cavity, the Subpatellar deep sac and the area between the patellar and the joints are mainly through the knee descending artery, the medial inferior knee, the lower lateral artery and its branches. The deep capsule of the patella is 0.9CM to 1.1cm, the width of 0.5cm, the height 0.3cm to 0.5cm, the length of the patellar ligament 4.5cm to 4.8cm; when the knee joint specimen is flexion (45), the deep capsule of the patellar is long 0.8 to 1.0cm, the width is at the maximum, and the distance between the lower margin of the patella and the tibial tuberosity is measured by the high 0.4cm to 0.6cm..
The morphologic characteristics of synovial membrane: the incidence of the synovium hardening in the upper patellar cartilage was 87% (26/30), the incidence of the synovium thickness greater than 5mm in the superior patellar capsule was 73% (22/30). The incidence of the surface roughness of the synovium in the deep capsule of the patellar was 70% (21/30), and the difference was significant (p0.001). The upper margin of the patellar cartilage, the synoviocytes at the posterior medial recess and the synovial cells and the synovial cells in the posterior medial part of the patellar cartilage The incidence of small vascular hyperplasia were 80% (24/30) and 57% (17/30) respectively. The incidence of interstitial fibrosis and hyaline change were 83% (25/30) and 74% (22/30) respectively, and there were significant differences compared with other parts (P0.001).
Quantitative determination of effusion: (1) MRI scan on the coronal plane of the knee: high signal in the articular cavity is visible at the middle point of the knee joint when 10 ml contrast agent is injected. (2) MRI scan at the medial sagittal plane of the knee joint: when the 5 ml contrast agent is 5, the high signal area is before the anterior condylar eminence, and the high signal is visible above the posterior medial condyle of the tibia, and the high signal is visible in the upper part of the medial condyle of the 70% tibia. MRI scan in the transverse section of the knee through the inferior patellar edge of the knee joint: when the contrast agent was 5 ml, the high signal was seen in the 1/3 segment of the 90% articular cavity; the contrast agent was 10 ml, and the high signal area appeared in the plane of the anterior margin of the femur.
Conclusion: the deep capsule of the patellar and the synovial membrane of the articular cavity are not extended, and the friction of the patellar ligament is one of the reasons for the formation of the synovial membrane. The deep capsule of the patellar, the upper patellar capsule, and the synovium at the upper edge of the patellar cartilage are easily morphologically changed. The synovial membrane of the posterior medial recess and the upper patellar cartilage is the most significant part of the histological change. It is important to establish the reference standard for different volumes of fluid with different amounts of contrast agents, which is of great value in the diagnosis of synovial pouch effusion around the knee joint cavity by MRI.

【学位授予单位】：重庆医科大学
【学位级别】：硕士
【学位授予年份】：2011
【分类号】：R322.72

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