Navicular malunion inowanikwa munenge 5-15% yezvose zvakaputsika zvakaputsika zve navicular bone, ine navicular necrosis inoitika munenge 3%. Zvikonzero zvengozi ye navicular malunion zvinosanganisira kupotsa kana kunonoka kuongororwa, kuswedera pedyo kwemutsara wekuputsika, kutama kunopfuura 1 mm, uye kuputsika ne carpal instability. Kana ikasiyiwa isina kubatwa, navicular osteochondral nonunion inowanzobatanidzwa nekurwadziwa kwearthritis, inozivikanwawo se navicular osteochondral nonunion ine collapsing osteoarthritis.
Bone grafting pamwe kana pasina vascularised flap inogona kushandiswa kurapa navicular osteochondral nonunion. Zvisinei, kune varwere vane osteonecrosis yeproximal pole ye navicular bone, migumisiro yemapfupa ekubatanidza pasina vascular tip haigutsikani, uye mapfupa ekuporesa chiyero che40% -67 chete%. Kusiyana neizvi, chiyero chekuporesa kwemapfupa emapfupa ane vascularised flaps anogona kunge akakwirira se88% -91%. Iwo makuru evascularised bone flaps mukuita kwekiriniki anosanganisira 1,2-ICSRA-tipped distal radius flap, bone graft + vascular bundle implant, palmar radius flap, yemahara iliac bone flap ine vascularised tip, uye medial femoral condylar bone flap (MFC VBG), etc. Migumisiro yemapfupa ekubatanidza ne vascularised tip inogutsa. Iyo MFC VBG yakasununguka yakaratidzwa kuti inoshanda mukurapa kwekuputsika kwemvura ine metacarpal kuputsika, uye MFC VBG inoshandisa articular bazi rekudzika kwemabvi arteri sebazi guru retrophic. Kuenzaniswa nemamwe maflaps, MFC VBG inopa rubatsiro rwakakwana rwekugadzirisa kudzorera chimiro chechimiro chepfupa remvura, kunyanya mu navicular fracture osteochondrosis ine bowed back deformity (Mufananidzo 1). Mukurapa kwe navicular osteochondral osteonecrosis ine kufambira mberi kwecarpal kudonha, iyo 1,2-ICSRA-tipped distal radius flap yakanzi ine bone kuporesa mwero we40% chete, nepo MFC VBG ine bone kuporesa mwero we100%.
Mufananidzo 1. Kuputsika kwepfupa remvura rine "bowed back" deformity, CT inoratidza kuputsika kwebhokisi pakati pemapfupa emvura pakona inenge ye90 °.
Preoperative kugadzirira
Mushure mekuongororwa kwemuviri kwechanza chakakanganisika, zvidzidzo zvekufungidzira zvinofanirwa kuitwa kuti zviongorore dhigirii rekudonha kweruoko. Plain radiographs inobatsira kusimbisa nzvimbo yekutyoka, dhigirii rekutamisa, uye kuvapo kweresorption kana sclerosis yegumo rakaputsika. Mifananidzo yepashure inoshandiswa kuongorora kudonha kwechanza, kusagadzikana kwemudhori kwechanza (DISI) uchishandisa yakagadziridzwa wrist urefu reshiyo (urefu/hupamhi) ye ≤1.52 kana radial lunate angle inopfuura 15 °. MRI kana CT inogona kubatsira kuongorora kusakanganiswa kwe navicular bone kana osteonecrosis. Lateral radiographs kana oblique sagittal CT ye navicular bone ine navicular angle> 45 ° inoratidza kupfupika kwepfupa remvura, iro rinozivikanwa se "bowed back deformity".MRI T1, T2 low signal inoratidza necrosis ye navicular bone, asi MRI ine hapana kukosha kwakajeka pakusarudza kuporeswa kwekuputsika.
Zviratidzo uye contraindications:
Navicular osteochondral nonunion ine akakotama musana kuremara uye DISI; MRI inoratidza ischemic necrosis ye navicular bone, intraoperative loosening ye tourniquet uye kutarisa kwekuputsika kwakaputsika kuguma kwe navicular bone ichiri white sclerotic bone; kutadza kwekutanga wedge bhonzo kubatanidza kana screw mukati mekugadzirisa kunoda hombe yeVGB structural bone grafting (＞1cm3). preoperative kana intraoperative zvakawanikwa zve osteoarthritis ye radial carpal joint; kana zvakakosha navicular malunion nekuputsika osteoarthritis yakaitika, ipapo kuparara kwemaoko, navicular osteotomy, quadrangular fusion, proximal carpal osteotomy, yakazara carpal fusion, nezvimwewo, inogona kudiwa; navicular malunion, proximal necrosis, asi neyakajairwa navicular bone morphology (semuenzaniso, isina-isina-isina kusimuka navicular kutyoka nekushaya ropa kugovera kune proximal pole); kupfupisa kwe navicular malunion pasina osteonecrosis. (1,2-ICSRA inogona kushandiswa sechinotsiva distal radius flap).
Applied Anatomy
Iyo MFC VBG inopiwa nenhamba yediki interosseous trophoblastic midziyo (inoreva 30, 20-50), ine ropa rakawanda rakawanda riri shure kwepasi kune medial femoral condyle (kureva 6.4), inoteverwa nepamusoro-soro (inoreva 4.9) ( Mufananidzo 2). Iyi midziyo yetrophoblastic yainyanya kupihwa neinodzika geniculate artery (DGA) uye/kana iyo yepamusoro medial geniculate artery (SMGA), inova bazi repamusoro pechikadzi artery iyo inopawo kusimuka kwearticular, musculocutaneous, uye/kana saphenous nerve matavi. . iyo DGA yakabva kune yepamusoro yefemoral artery proximal kusvika kune yepakati eminence yemedial malleolus, kana iri chinhambwe che 13.7 cm proximal kune articular surface (10.5-17.5 cm), uye kugadzikana kwebazi kwaive 89% mune cadaveric specimens. (Mufananidzo 3). Iyo DGA inotangira pane yepamusoro yefemoral artery pa 13.7 cm (10.5 cm-17.5 cm) proximal kune medial malleolus fissure kana proximal kune articular surface, ine cadaveric specimen inoratidza 100% branching kugadzikana uye dhayamita inosvika 0.78 mm. Nokudaro, kana DGA kana SMGA inogamuchirwa, kunyange zvazvo yekare inonyanya kukodzera tibiae nekuda kwehurefu uye dhayamita yemudziyo.
Mufananidzo 2. Zvine-quadrant kugoverwa kwemidziyo yeMFC trophoblast pamwe chete nemutsara wakadzika pakati pe semitendinosus uye medial collateral ligament A, mutsara we trochanter yakakura B, mutsara wepamusoro wepa patella C, mutsara we anterior meniscus D.
Mufananidzo 3. MFC vascular anatomy: (A) Matavi akawandisa uye MFC trophoblastic vascular anatomy, (B) Kureba kwevascular mavambo kubva kumutsara wekubatana
Kuvhiya kuwana
Murwere anogadzikwa pasi peanesthesia munzvimbo yepamusoro, uye nhengo inobatwa ichiiswa patafura yekuvhiya ruoko. Kazhinji, iyo donor bone flap inotorwa kubva kune ipsilateral medial femoral condyle, kuitira kuti murwere agone kufamba nemadondoro mushure mekuvhiyiwa. Iyo contralateral ibvi inogonawo kusarudzwa kana pane nhoroondo yezvakaitika kare kana kuvhiyiwa kune rumwe rutivi rwemabvi. Ibvi rinogadziriswa uye chiuno chinotenderera kunze, uye tourniquets inoshandiswa kune zvose zviri kumusoro uye pasi. Nzira yekuvhiya yaiva nzira yakawedzerwa yeRusse, nekucheka kunotanga 8 cm kuswedera kune inotenderera carpal tunnel uye kuenderera kure kubva kumucheto weradial flexor carpi radialis tendon, uyezve kupeta pamugero we carpal wakananga kuzasi kwechigunwe. , kupera pamwero we trochanter yakakura. Iyo tendon sheath ye radial longissimus tendon yakanyungudutswa uye tendon inotorwa ulnarly, uye pfupa remvura rinoratidzwa nekutsemuka kwakapinza pamwe neiyo radial lunate uye radial navicular head ligaments, nekunyatso kupatsanurwa kweperipheral soft tissues ye navicular bone kubvumira. kuwedzera kuratidzwa kwe navicular bone (Mufananidzo 4). Simbisa nzvimbo yekusabatana, kunaka kwe articular cartilage uye chiyero che ischaemia ye navicular bone. Mushure mokusunungura tourniquet, cherechedzai danda repamusoro pepfupa remvura yepunctate kubuda ropa kuti uone kana pane ischemic necrosis. Kana iyo navicular necrosis isingabatanidzwe neradial carpal kana intercarpal arthritis, MFC VGB inogona kushandiswa.
Mufananidzo 4. Nzira yekuvhiya yeNavicular: (A) Iyo incision inotanga 8 cm kusvika kune inotenderera carpal tunnel uye inowedzera radial edge ye radial flexor carpi radialis tendon kusvika kune distal part of the incision, iyo inopetwa yakananga kuzasi kwechigunwe. pamhanza yecarpal tunnel. (B) Iyo tendon sheath ye radial longissimus tendon inoputika uye tendon inotorwa ulnarly, uye pfupa remvura rinoratidzwa nekuparadzanisa kwakapinza pamwe chete neradial lunate uye radial navicular head ligaments. (C) Ziva nzvimbo ye navicular osseous discontinuity.
A 15-20 cm kureba incision inoitwa proximal kusvika ibvi akabatana mutsara pamwe nechekumashure muganhu wepakati femoral tsandanyama, uye tsandanyama inodzokororwa mberi kufumura MFC ropa kupa (Fig. 5) .The MFC ropa rinopiwa kazhinji kupiwa. nematavi articular eDGA uye SMGA, kazhinji achitora yakakura yakabatana bazi reDGA uye inofambidzana inoperekedza tsinga. The vascular pedicle inosunungurwa proximally, kutarisira kuchengetedza periosteum uye trophoblastic midziyo pamusoro bony pamusoro.
Mufananidzo 5. Kupinda kwekuvhiya kuMFC: (A) A 15-20 cm kureba incision inoitwa proximally pamwe neshure muganhu wepakati femoral muscle kubva pamabvi akabatanidzwa mutsara. (B) Iyo tsandanyama inodzoserwa mberi kuratidza iyo MFC ropa rekupa..
Kugadzirira kwe navicular bone
The navicular DISI deformity inofanira kugadziriswa uye nzvimbo ye osteochondral bone graft yakagadzirirwa isati yasimwa nekugadzirisa wrist pasi pe fluoroscopy kudzorera yakajairika radial lunate angle (Mufananidzo 6). A 0.0625-foot (inenge 1.5-mm) Kirschner pini inoboorwa percutaneously kubva kudorsal kusvika kumetacarpal kugadzirisa radial lunate joint, uye navicular malunion gap inobuda pachena kana wrist yatwasanuka. Nzvimbo yekutyoka yakacheneswa zvinyoro zvinyoro uyezve yakavhurika neplate spreader. Saha diki inodzoreredza inoshandiswa kudzikamisa bhonzo uye kuona kuti iyo yekuisirwa flap yakafanana neyakawanda yerectangular chimiro pane wedge, izvo zvinoda kuti gap remugungwa ribatwe nepakapamhama padivi repalmar pane kudivi remushure. Mushure mokuvhura gap, chirema chinopimwa muzvikamu zvitatu kuti zvione kuwanda kwepfupa, iyo inowanzoita 10-12 mm kureba kumativi ose egraft.
Mufananidzo 6. Kugadziriswa kwekuremara kwemashure ekuremara kwekufamba, ne fluoroscopic flexion of wrist kudzorera yakajairika radial-lunar alignment. A 0.0625-foot (inenge 1.5-mm) Kirschner pini inoboorwa percutaneously kubva kudorsal kusvika kune metacarpal kugadzirisa radial lunate joint, kuratidza navicular malunion gap uye kudzorera hurefu hwepamusoro hwebhonzo rekufamba apo ruoko rwakatwasuka, nehukuru hwe. mukaha unofanotaura kukura kwechipipe chinoda kubatwa.
Osteotomy
Nharaunda yevascularised ye medial femoral condyle inosarudzwa senzvimbo yekubvisa pfupa, uye nzvimbo yekubvisa pfupa yakanyatsoratidzwa. Chenjerera kuti usakuvadza medial collateral ligament. Iyo periosteum incised, uye rectangular bone flap yehukuru hwakakodzera hwechifukidzo chinodiwa inochekwa nesaha inodzokororwa, ine chechipiri chepfupa yakachekwa pa 45 ° pamwe nerumwe rutivi kuti ivimbise kuvimbika kwembambo (Fig. 7). 7). Kuchengetedza kunofanira kutorwa kusaparadzanisa periosteum, cortical bone, uye cancellous bone yeflap. Iyo yakaderera yekupedzisira tourniquet inofanirwa kuburitswa kuti ione kuyerera kweropa kuburikidza nembavha, uye iyo vascular pedicle inofanira kusunungurwa proximally kweinenge 6 cm kubvumira inotevera vascular anastomosis. Kana zvichidikanwa, chidimbu chiduku chepfupa rekuregererwa chinogona kuenderera mberi mukati memukondori wevakadzi. Iyo femoral condylar defect yakazadzwa nepfupa graft inotsiva, uye iyo incision inodonhedzwa uye yakavharwa dhizaini.
Mufananidzo 7. MFC bone flap kubviswa. (A) Nzvimbo ye osteotomy inokwana kuzadza nzvimbo yekufamba inotarwa, periosteum inochekwa, uye rectangular bone bhapa rehukuru hwakakodzera hwechinodiwa chinotemwa chinochekwa nesaha inodzokororwa. (B) Chikamu chechipiri chepfupa chinochekwa pamwe chete kune rumwe rutivi pa 45 ° kuti ive nechokwadi chekuvimbika kwechiputi.
Flap implantation uye kugadzirisa
Iyo pfupa pfupa inogadziriswa kune iyo yakakodzera chimiro, kuchenjerera kuti usamanikidza vascular pedicle kana kubvisa periosteum. Iyo flap inodyarwa zvinyoro nyoro munzvimbo ye navicular bone chirema, kudzivirira kubhuroka, uye yakagadziriswa ine hollow navicular screws. Chengetedzo yakatorwa kuti ive nechokwadi chekuti mucheto webhonzo rakasimwa waive wakapfava nemuganho wepammar yebhonzo remumvura kana kuti raive rakaora mwoyo zvishoma kudzivirira kupindira. Fluoroscopy yakaitwa kusimbisa navicular bone morphology, mutsara wesimba uye screw position. Anastomose iyo vascular flap artery kune radial arteri inopera kune rumwe rutivi uye iyo venous tip kune radial arteri shamwari tsinga inopera kusvika kumagumo (Mufananidzo 8). Iyo capsule yakabatana inogadziriswa, asi vascular pedicle inodziviswa.
Mufananidzo 8. Bone flap implantation, kugadzirisa, uye vascular anastomosis. Iyo pfupa inoputika inoiswa zvinyoro-nyoro munzvimbo ye navicular bone defect uye yakagadziriswa nehollow navicular screws kana Kirschner pini. Chengetedzo inotorwa kuti metacarpal margin yeiyo yakasimwa bone block inotsvedza ne metacarpal margin ye navicular bone kana kupfaviswa kuora mwoyo kudzivirira kupinza. Anastomosis yevascular flap artery kune radial artery yakaitwa kumagumo kusvika kumagumo, uye iyo tsinga yetsinga kune radial arteri shamwari tsinga yakaitwa kupera kusvika kumagumo.
Postoperative rehabilitation
Oral aspirin 325 mg pazuva (kwemwedzi 1), mushure mekushanda uremu-kutakura kwenhengo yakakanganiswa inobvumirwa, kubvongodzwa kwemabvi kunogona kuderedza kusagadzikana kwemurwere, zvichienderana nekukwanisa kwemurwere kufamba panguva yakakodzera. Contralateral kutsigirwa kwetsvimbo imwe chete kunogona kuderedza marwadzo, asi kutsigirwa kwenguva refu kwemadondoro hakudiwi. Misono yacho yakabviswa mavhiki maviri mushure mekuvhiyiwa uye Muenster kana ruoko rwakareba kusvika kune chigunwe chakachengetwa munzvimbo kwemavhiki matatu. Mushure maizvozvi, ruoko rupfupi kune chigunwe chinoshandiswa kusvikira kuputsika kwapora. X-rays inotorwa pamasvondo e3-6, uye kuporeswa kwekuputsika kunosimbiswa neCT. Mushure mezvo, kushanda uye kusinganzwisisi kushanduka uye mabasa ekuwedzera anofanirwa kutangwa zvishoma nezvishoma, uye kusimba uye kuwanda kwekurovedza muviri kunofanira kuwedzerwa zvishoma nezvishoma.
Matambudziko makuru
Matambudziko makuru emabvi akabatanidzwa anosanganisira kurwadziwa kwemabvi kana kukuvara kwetsinga. Marwadzo emabvi ainyanya kuitika mukati memavhiki e6 mushure mekuvhiyiwa, uye hapana kurasikirwa kwekunzwa kana neuroma inorwadza nekuda kwekukuvara kwetsinga ye saphenous yakawanikwa. Matambudziko makuru echanza aisanganisira refractory bone nonunion, kurwadziwa, kuomarara kwemajoini, kushaya simba, kufambira mberi kweosteoarthritis yeradial wrist kana intercarpal mapfupa, uye njodzi yeperiosteal heterotopic ossification yakataurwa zvakare.
Yemahara Medial Femoral Condyle Vascularised Bone Grafting yeScaphoid Nonunions ine Proximal Pole Avascular Necrosis uye Carpal Collapse.
Nguva yekutumira: May-28-2024
