Kutsemuka kwemapfupa emusana kunoitika muchikamu chinosvika 5-15% chemapfupa ese akatsemuka, nekuputika kwemapfupa emusana kunoitika muchikamu chinosvika 3%. Zvinhu zvinokonzera njodzi yekukuvara kwemapfupa emusana zvinosanganisira kunonoka kuongororwa, kuswedera pedyo kwemutsara wekutsemuka, kusuduruka kwemapfupa kupfuura 1 mm, uye kutsemuka kwemapfupa nekuda kwekusagadzikana kwemapfupa. Kana zvikasarapwa, kutsemuka kwemapfupa emusana kunowanzobatanidzwa nechirwere chearthritis chinonzi traumatic arthritis, chinozivikanwawo sechirwere che osteochondral nonunion chine chirwere chinodonha che osteoarthritis.
Kubatanidza mapfupa uchishandisa kana usina vascularised flap kunogona kushandiswa kurapa navicular osteochondral nonunion. Zvisinei, kune varwere vane osteonecrosis yeproximal pole ye navicular bone, mhedzisiro yekusanganisa mapfupa pasina vascular tip haigutsi, uye mwero wekupora kwemapfupa i40%-67 chete. Kusiyana neizvi, mwero wekupora kwemapfupa ane vascularised flaps unogona kusvika pa88%-91%. Ma vascularised bone flaps makuru mukiriniki anosanganisira 1,2-ICSRA-tipped distal radius flap, bone graft + vascular bundle implant, palmar radius flap, free iliac bone flap ine vascularised tip, uye medial femoral condylar bone flap (MFC VBG), nezvimwewo. Mhedzisiro yekusanganisa mapfupa ne vascularised tip inogutsa. Free MFC VBG yakaratidzwa kuti inoshanda mukurapa kuputsika kwe navicular ne metacarpal collapse, uye MFC VBG inoshandisa articular branch ye descending knee artery sebazi guru re trophic. Zvichienzaniswa nedzimwe mapfupa, MFC VBG inopa rutsigiro rwakakwana rwechimiro kuti idzorere chimiro chepfupa remusana, kunyanya mumapfupa emusana ane mapfupa akatyoka ane musana wakakombama (Mufananidzo 1). Mukurapa kwemapfupa emusana ane mapfupa ane mapfupa ane mapfupa akatyoka, mapfupa emusana ane mapfupa ane mapfupa akawanda anonzi ane mapfupa anoporesa nemapfupa e40% chete, nepo MFC VBG ine mapfupa anoporesa nemapfupa e100%.
Mufananidzo 1. Kutyoka kwepfupa reruzhowa rine "kukotama kumashure", CT inoratidza kutyoka pakati pemapfupa eruzhowa pakona yeinenge 90°.
Kugadzirira usati wavhiyiwa
Mushure mekuongororwa kweruoko rwakakanganiswa, zvidzidzo zvemifananidzo zvinofanirwa kuitwa kuti zvionekwe kuti ruoko rwakaputsika zvakadii. MaX-ray akajeka anobatsira kusimbisa nzvimbo yakaputsika, mwero wekusuduruka, uye kuvapo kwe resorption kana sclerosis yemucheto wakatyoka. Mifananidzo yekumashure inoshandiswa kuongorora kuputsika kweruoko, kusagadzikana kweruoko (DISI) uchishandisa modified wrist height ratio (kukwirira/upamhi) ye ≤1.52 kana radial lunate angle inopfuura 15°. MRI kana CT inogona kubatsira kuongorora kusarongeka kwepfupa renavicular kana osteonecrosis. MaX-ray adivi kana oblique sagittal CT yepfupa renavicular ine navicular angle >45° inoratidza kupfupika kwepfupa renavicular, iro rinozivikanwa se "bowed back deformity". MRI T1, T2 low signal inoratidza necrosis yepfupa renavicular, asi MRI haina kukosha kwakajeka mukuona kuporeswa kwepfupa.
Zviratidzo uye contraindications:
Kusabatana kwemapfupa emusana ane musana wakakotama uye DISI; MRI inoratidza ischemic necrosis yepfupa remusana, kusunungurwa kwetourniquet mukati mekuvhiyiwa uye kuona kutyoka kwakatyoka kwepfupa remusana richiri pfupa jena resclerotic; kukundikana kwekubatanidza mapfupa ekutanga kana screw fixation yemukati kunoda VGB structural bone grafting yakakura (> 1cm3). kuwanikwa kwe osteoarthritis ye radial carpal joint isati yavhiyiwa kana mukati mekuvhiyiwa; kana navicular malunion yakakosha ine collapsing osteoarthritis yakaitika, ipapo wrist denervation, navicular osteotomy, quadrangular fusion, proximal carpal osteotomy, total carpal fusion, nezvimwewo, zvinogona kudiwa; navicular malunion, proximal necrosis, asi ne navicular bone morphology yakajairika (semuenzaniso, non-displaced navicular fracture neropa risinganyanyi kuwanikwa ku proximal pole); kupfupika kwe navicular malunion isina osteonecrosis. (1,2-ICSRA inogona kushandiswa panzvimbo pe distal radius flap).
Kushandiswa kweAnatomy
MFC VBG inopihwa netsinga diki dze trophoblastic dzakapatsanurwa (pakati pe30, 20-50), ropa rakawanda riri pasi pe medial femoral condyle (pakati pe6.4), richiteverwa ne anteriorly superior (pakati pe4.9) (Mufananidzo 2). Dzimba idzi dze trophoblastic dzainyanya kupihwa ne descending geniculate artery (DGA) uye/kana superior medial geniculate artery (SMGA), inova bazi re superficial femoral artery rinopawo articular, musculocutaneous, uye/kana saphenous nerve branches. DGA yakabva pa superficial femoral artery iri pedyo ne medial eminence ye medial malleolus, kana kuti iri pa 13.7 cm proximal kusvika pamusoro pe articular (10.5-17.5 cm), uye kugadzikana kwe branching kwaive 89% mu cadaveric specimens (Mufananidzo 3). DGA inobva pamuromo wetsinga wepamusoro wefemoral uri pa13.7 cm (10.5 cm-17.5 cm) uri pedyo nepakati pemalleolus fissure kana kuti uri pedyo nepamusoro pe articular, ine chitunha chinoratidza kugadzikana kwe100% kwematavi uye dhayamita inosvika 0.78 mm. Saka, DGA kana SMGA zvinogamuchirwa, kunyangwe yekutanga yakakodzera tibiae nekuda kwehurefu nedhayamita yemudziyo.
Mufananidzo 2. Kugoverwa kwemidziyo yeMFC trophoblast ine zvikamu zvina pamutsetse wakatwasuka pakati pesemitendinosus ne medial collateral ligament A, mutsetse we greater trochanter B, mutsetse we superior pole ye patella C, mutsetse we anterior meniscus D.
Mufananidzo 3. Kuumbwa kwetsinga dzeropa dzeMFC: (A) Matavi akawandisa uye MFC trophoblastic vascular anatomy, (B) Kureba kwenzvimbo dzakatangira tsinga dzeropa kubva pamutsetse wejoini
Kupinda pakuvhiyiwa
Murwere anoiswa pasi peanesthesia yakajairika ari panzvimbo yakarara, gumbo rakakanganiswa rakaiswa patafura yekuvhiyiwa kweruoko. Kazhinji, pfupa remupi wemapfupa rinotorwa kubva ku ipsilateral medial femoral condyle, kuitira kuti murwere agone kufamba nemadondoro mushure mekuvhiyiwa. Ibvi repamberi rinogonawo kusarudzwa kana paine nhoroondo yekukuvara kwakamboitika kana kuvhiyiwa kudivi rimwe chete rebvi. Ibvi rinotenderedzwa uye chiuno chinotenderedzwa kunze, uye matourniquets anoiswa kumativi ese ekumusoro neapasi. Nzira yekuvhiya yaive nzira yakawedzerwa yeRusse, nekucheka kunotanga 8 cm pedyo ne transverse carpal tunnel uye kuchienda kure kubva kumucheto we radial we radial flexor carpi radialis tendon, uye wozopetwa pa transverse carpal tunnel kuenda pasi pechigunwe, zvichiguma padanho re greater trochanter. Mutsipa wetendon we radial longissimus tendon unochekwa uye tendon inodhonzwa ulnarly, uye pfupa re navicular rinoonekwa nekukasira kupatsanurwa pamwe chete ne radial lunate uye radial navicular head ligaments, nekunyatsoparadzanisa peripheral soft tissues ye navicular bone kuti pfupa re navicular riwedzere kuonekwa (Mufananidzo 4). Simbisa nzvimbo isina kubatana, mhando ye articular cartilage uye mwero we ischemia yepfupa re navicular. Mushure mekusunungura tourniquet, tarisa proximal pole ye navicular bone kuti uone kana paine ischemic necrosis. Kana navicular necrosis isina kubatana ne radial carpal kana intercarpal arthritis, MFC VGB inogona kushandiswa.
Mufananidzo 4. Nzira yekuvhiya yeNavicular: (A) Kuchekwa kunotanga ne8 cm pedyo ne transverse carpal tunnel uye kunotambanudza radial edge ye radial flexor carpi radialis tendon kusvika kudivi rekure re incision, iro rinopetwa richienda pasi pechigunwe pa transverse carpal tunnel. (B) Chidimbu che tendon che radial longissimus tendon chinochekwa uye tendon inodhonzwa ulnarly, uye pfupa re navicular rinoonekwa nekutsemuka kwakapinza pamwe chete ne radial lunate uye radial navicular head ligaments. (C) Tsvaga nzvimbo ye navicular osseous discontinuity.
Kuchekwa kwe 15-20 cm kureba kunochekwa pedyo nemutsara wegumbo pamucheto wekumashure wemhasuru yepakati yefemoral, uye tsandanyama inodzoserwa mberi kuti ropa reMFC rionekwe (Mufananidzo 5). Kuwanikwa kweropa reMFC kunowanzo pihwa nemapazi eDGA neSMGA, kazhinji zvichitora bazi guru reDGA netsinga inoenderana naro. Pedcle yetsinga inosunungurwa pedyo, ichichengetedza periosteum nemidziyo yetrophoblastic pamusoro pemapfupa.
Mufananidzo 5. Kuvhiyiwa kweMFC: (A) Kuchekwa kwe 15-20 cm kureba kunoitirwa pedyo nemuganhu wekumashure wemhasuru yepakati yefemoral kubva pamutsetse wegumbo. (B) Tsandanyama inodzoserwa kumashure kuti ropa reMFC rionekwe.。
Kugadzirira pfupa remusana
Kukanganisika kwemapfupa e-navicular DISI kunofanirwa kugadziriswa uye nzvimbo ye-osteochondral bone graft inogadzirwa isati yaiswa nekutendeudza ruoko pasi pe fluoroscopy kuti idzorere radial lunate angle yakajairika (Mufananidzo 6). Pini yeKirschner ine 0.0625-foot (inenge 1.5-mm) inoboorwa percutaneously kubva dorsal kuenda ku metacarpal kuti igadzire radial lunate joint, uye navicular malunion gap inoonekwa kana ruoko rwatwasanudzwa. Nzvimbo yekutyoka yakabviswa soft tissue ndokuzovhurwa ne plate spreader. Saha diki rinodzokororwa rinoshandiswa kuti pfupa rive rakatsetseka uye kuve nechokwadi chekuti implant flap yakafanana ne rectangular structure kupfuura wedge, izvo zvinoda kuti navicular gap ibatwe ne gap yakakura kudivi repalmar pane kudivi redorsal. Mushure mekuvhura gap, defect inoyerwa muzvikamu zvitatu kuti ione kuti mapfupa akabatanidzwa sei, ayo anowanzo kuve 10-12 mm pakureba kumativi ese egraft.
Mufananidzo 6. Kugadziriswa kwekuremara kwemusana wakakotama weruboshwe rweruoko, ne fluoroscopic flexion yeruoko kuti kudzoreredze kurongeka kwakajairika kwe radial-lunar. Pini yeKirschner ine 0.0625-foot (inenge 1.5-mm) inoboorwa percutaneously kubva dorsal kuenda ku metacarpal kuti igadzire radial lunate joint, ichiratidza navicular malunion gap uye ichidzorera kukwirira kwakajairika kwepfupa reruboshwe kana ruoko rwatwasanudzwa, nehukuru hwegap huchifanotaura saizi yeflap ichada kubatwa.
Osteotomy
Nzvimbo ine tsinga dzeropa dze medial femoral condyle inosarudzwa senzvimbo inotorwa mapfupa, uye nzvimbo inotorwa mapfupa inocherechedzwa zvakakwana. Chenjerera kuti usakuvadze medial collateral ligament. Periosteum inochekwa, uye pfupa rectangular rehukuru hwakakodzera hwe flap inodiwa rinochekwa nesaha rinodzokororwa, nechikamu chechipiri chepfupa chinochekwa pa 45° parutivi rumwe kuti ive nechokwadi chekuti flap yakamira zvakanaka (Mufananidzo 7). 7). Chenjerera kuti usaparadzanise periosteum, cortical bone, uye cancellous bone ye flap. Tourniquet yepazasi pemucheto inofanira kusunungurwa kuti ione kuyerera kweropa kuburikidza ne flap, uye vascular pedicle inofanira kusunungurwa pedyo ne 6 cm kuti ibvumire vascular anastomosis inotevera. Kana zvichidikanwa, pfupa diki re cancellous rinogona kuenderera mberi mukati me femoral condyle. Femoral condylar defect inozadzwa ne bone graft substitute, uye incision inodururwa uye inovharwa layer ne layer.
Mufananidzo 7. Kubviswa kweMFC bone flap. (A) Nzvimbo ye osteotomy yakakwana kuzadza nzvimbo ye navicular inonyorwa, periosteum inochekwa, uye rectangular bone flap yehukuru hwakakodzera yeflap inodiwa inochekwa nesaha rinodzokororwa. (B) Chikamu chechipiri chepfupa chinochekwa parutivi rumwe pa45° kuti chive nechokwadi chekuti flap yacho yakasimba.
Kuisa flap uye kugadzirisa
Chifukidziro chepfupa chinochekwa kuti chikwane chimiro chakakodzera, zvichichenjererwa kuti chisadzvanyirire pedicle yeropa kana kubvisa periosteum. Chifukidziro chinoiswa zvinyoro nyoro munzvimbo ine defect yepfupa renavicular, kudzivirira kurira, uye chinogadziriswa nehollow navicular screws. Kwakatariswa kuti pave nechokwadi chekuti pamucheto wepalmar we block yepfupa rakaiswa wakanyatsojeka ne pamucheto wepalmar wepfupa renavicular kana kuti wakadzikiswa zvishoma kudzivirira kubatwa. Fluoroscopy yakaitwa kusimbisa chimiro chepfupa renavicular, line of force uye screw position. Anastomose vascular flap artery kumucheto weradial artery kuenda kudivi uye venous tip kuenda kumucheto weradial artery inoenderana nevein kusvika kumagumo (Mufananidzo 8). Joint capsule inogadziriswa, asi vascular pedicle inodziviswa.
Mufananidzo 8. Kuiswa kwemapfupa, kugadziriswa, uye kupatsanurwa kwetsinga dzeropa. Chifukidzo chepfupa chinoiswa zvinyoro nyoro munzvimbo ine defect yepfupa renavicular uye chinogadziriswa ne hollow navicular screws kana mapini eKirschner. Chenjerera kuti muganho we metacarpal webhonzo rakaiswa unyatsobuda ne metacarpal muganho wepfupa renavicular kana kuti unyatsodzikiswa zvishoma kudzivirira kubatwa. Kuongororwa kweropa re vascular flap artery kuenda ku radial artery kwakaitwa kubva kumagumo kusvika kumagumo, uye muganho wetsinga kuenda ku radial artery companion vein wakaitwa kubva kumagumo kusvika kumagumo.
Kurapwa mushure mekuvhiyiwa
Aspirin inonwiwa 325 mg pazuva (kwemwedzi mumwe chete), kutakura uremu mushure mekuvhiyiwa kwegumbo rakakanganiswa kunobvumirwa, kubhurika kwebvi kunogona kuderedza kusagadzikana kwemurwere, zvichienderana nekukwanisa kwemurwere kufamba panguva yakakodzera. Kutsigira crutch imwe chete kunogona kuderedza marwadzo, asi kutsigira crutch kwenguva refu hakudiwi. Misono yakabviswa mavhiki maviri mushure mekuvhiyiwa uye Muenster kana kuti cast refu kubva paruoko kuenda parukumwe yakachengetwa panzvimbo yayo kwemavhiki matatu. Mushure meizvozvo, cast pfupi kubva paruoko kuenda parukumwe inoshandiswa kusvika breakdown yapora. X-rays inotorwa kwemavhiki matatu kusvika matanhatu, uye kupora kwebreakdown kunosimbiswa neCT. Mushure meizvozvo, mabasa ekushanda uye epassive flexion uye extension anofanirwa kutanga zvishoma nezvishoma, uye simba uye nguva yekurovedza muviri inofanira kuwedzerwa zvishoma nezvishoma.
Matambudziko makuru
Matambudziko makuru egumbo anosanganisira kurwadziwa kwebvi kana kukuvara kwetsinga. Marwadzo ebvi aiwanzoitika mukati memavhiki matanhatu mushure mekuvhiyiwa, uye hapana kurasikirwa kwemanzwiro kana neuroma inorwadza nekuda kwekukuvara kwetsinga yakabatana. Matambudziko makuru echigunwe aisanganisira kusabatana kwemapfupa, kurwadziwa, kuomarara kwemajoini, kushaya simba, osteoarthritis inofambira mberi yeruoko rwechigunwe kana mapfupa epakati pecarpal, uye njodzi ye periosteal heterotopic ossification yakataurwawo.
Kugadziriswa Kwemapfupa Emukati Medium Femoral Condyle Kwemahara KwemaScaphoid Nonunions NeProximal Pole Avascular Necrosis uye Carpal Collapse
Nguva yekutumira: Chivabvu-28-2024
