Nzira ye suprapatellar inzira yakagadziriswa yekuvhiya ye tibial intramedullary nail iri panzvimbo yebvi yakatambanudzwa zvishoma. Kune zvakanakira zvakawanda, pamwe nezvakaipa, zvekuita intramedullary nail ye tibia uchishandisa nzira ye suprapatellar munzvimbo ye hallux valgus. Vamwe vanachiremba vakajaira kushandisa SPN kurapa mavanga ese e tibial kunze kwekutyoka kwe extra-articular kwe proximal 1/3 ye tibia.
Zviratidzo zveSPN ndeizvi:
1. Kutyoka kwetsinga yetibial kwakachekwa kana kuti kwakapatsanuka. 2;
2. kutyoka kwe distal tibial metaphysis;
3. kutyoka kwehudyu kana ibvi nekutadza kugonya (semuenzaniso, chiuno chinopera simba kana kusanganiswa, osteoarthritis yebvi) kana kutadza kugonya ibvi kana chiuno (semuenzaniso, kutyoka kwechiuno kumashure, kutyoka kweipsilateral femur);
4. kutyoka kwetibial pamwe chete nekukuvara kweganda patendon ye infrapatellar;
5. kutyoka kwetibial mumurwere ane tibia yakareba zvakanyanya (mugumo wetibia unowanzo kuoma kuona pasi pe fluoroscopy kana kureba kwetibia kuchipfuura kureba kwetripod iyo fluoroscopy inogona kupfuura nayo).
Kubatsira kwenzira yekurapa nzara dzepakati petibial netibial intramedullary pakurapa mid-tibial diaphysis uye distal tibial fractures kuri nyore pakudzoreredza nzvimbo uye nyore kushandisa fluoroscopy. Nzira iyi inobvumira rutsigiro rwakanaka rwehurefu hwetibial uye nyore nyore kuderedza kutyoka kwetibial pasina chikonzero chekugadzirisa (Mifananidzo 1, 2). Izvi zvinobvisa kudiwa kwemubatsiri akadzidziswa kuti abatsire nehunyanzvi hwendarira dzemukati metibial.
Mufananidzo 1: Nzvimbo yakajairika yemaitiro echipikiri chemudumbu chemudumbu chemudumbu chemudumbu chemudumbu: ibvi riri panzvimbo yakachinjika pa tripod inopinzwa ne fluoroscopically. Zvisinei, nzvimbo iyi inogona kuwedzera kusarongeka kwe fracture block uye inoda mamwe matekiniki ekuderedza fracture.
Mufananidzo 2: Kusiyana neizvi, nzvimbo yakatambanudzwa yebvi panzvimbo yefoam ramp inobatsira kurongeka kwemabhuroko ekutyoka uye kugadziriswa kunotevera.
Maitiro Ekuvhiya
Tafura/Chinzvimbo Murwere anorara akarara pamubhedha we fluoroscopic. Kubata makumbo epasi kunogona kuitwa, asi hazvidikanwi. Tafura yeMitsipa yeropa yakakodzera nzara ye suprapatellar approach tibial intramedullary, asi hazvidikanwi. Zvisinei, mibhedha yakawanda yekupwanyika kana mibhedha ye fluoroscopic haikurudzirwi sezvo isingakodzeri nzara ye suprapatellar approach tibial intramedullary.
Kuisa chidya cheipsilateral kunobatsira kuchengetedza mugumo wepazasi uri panzvimbo yakatenderedzwa nekunze. Foam ramp inoshandiswa kusimudza gumbo rakabatwa pamusoro pedivi repamberi kuti ishandiswe fluoroscopy, uye nzvimbo yakatenderedzwa yechiuno nebvi inobatsirawo pakutungamira nzvimbo yepini nemukati memedullary. Kona yakanaka yekutenderera kwebvi ichiri kukakavadzana, Beltran nevamwe vake vachiratidza kutenderera kwebvi kwe10° uye Kubiak vachiratidza kutenderera kwebvi kwe30°. Nyanzvi zhinji dzinobvumirana kuti maangle ekutenderera kwebvi mukati meaya maerekitironi anogamuchirwa.
Zvisinei, Eastman nevamwe vake vakaona kuti sezvo kona yekutenderera kwebvi yaiwedzera zvishoma nezvishoma kubva pa10° kusvika pa50°, simba remuromo wemukadzi pakupinza kwechinhu chacho rakadzikira. Nokudaro, kona yakakura yekutenderera kwebvi ichabatsira pakusarudza nzvimbo chaiyo yekupinda kwembambo mukati memedullary uye kugadzirisa maburi emakona mu sagittal plane.
Fluoroscopy
Muchina weC-arm unofanira kuiswa kune rimwe divi retafura kubva kune chikamu chakakanganiswa, uye kana chiremba akamira padivi rebvi rakakanganiswa, monitor inofanira kunge iri pamusoro pemuchina weC-arm uye iri pedyo. Izvi zvinobvumira chiremba wechiremba ne radiologist kuti vaone zviri nyore monitor, kunze kwekunge paine chipikiri chakabatanidza kure. Kunyangwe zvisiri zvekumanikidzwa, vanyori vanokurudzira kuti C-arm iendeswe kune rimwe divi uye chiremba wechiremba aende kune rimwe divi apo sikuruu yekuchinjika kwepakati inofanira kufambiswa. Neimwe nzira, muchina weC-arm unofanirwa kuiswa kune rimwe divi rakakanganiswa uku chiremba wechiremba achiita maitiro acho kune rimwe divi (Mufananidzo 3). Iyi ndiyo nzira inonyanya kushandiswa nevanyori nekuti inodzivisa kudiwa kwekuti chiremba wechiremba achinje kubva kudivi repakati kuenda kudivi repadivi paanofambisa chipikiri chekuchinjika chedistal.
Mufananidzo 3: Chiremba anomira kune rimwe divi retibia yakakuvara kuitira kuti sikuruu yepakati inopindirana ikwanise kufambiswa zviri nyore. Chiratidziro chiri pamberi pechiremba, pamusoro peC-arm.
Maonero ese e fluoroscopic anowanikwa pamberi pechiso uye pakati pechiso nepadivi anowanikwa pasina kufambisa gumbo rakakanganiswa. Izvi zvinodzivirira kusuduruka kwenzvimbo yakatyoka yagadziriswazve kutyoka kusati kwagadziriswa zvachose. Pamusoro pezvo, mifananidzo yehurefu hwese hwe tibia inogona kuwanikwa pasina kutsveyamisa C-arm nenzira yakatsanangurwa pamusoro apa.
Kuchekwa kweganda: Kuchekwa kweganda kwakaganhurirwa uye kwakatambanudzwa zvakanaka kwakakodzera. Nzira ye percutaneous suprapatellar yekushandisa intramedullary nail inobva pakushandisa 3-cm incision kuti irovere nzara. Mazhinji emachekwa aya ekuvhiya ndee longitudinal, asi anogonawo kuva akachinjika, sezvakakurudzirwa naDr. Morandi, uye kucheka kwakachinjika kunoshandiswa naDr. Tornetta nevamwe kunoratidzwa kuvarwere vane combined patellar subluxation, vane nzira inonyanya kushandiswa pa medial kana lateral papatellar. Mufananidzo 4 unoratidza machekwa akasiyana.
Mufananidzo 4: Mufananidzo wenzira dzakasiyana dzekucheka mapfupa ekuvhiya.1- Nzira yeSuprapatellar transpatellar ligament; 2- Nzira yeParapatellar ligament; 3- Nzira yeMedial limited incision parapatellar ligament; 4- Nzira yeMedial prolonged incision parapatellar ligament; 5- Nzira yeLateral parapatellar ligament. Kuonekwa kwakadzika kwenzira yeparapatellar ligament kunogona kuitika kuburikidza nejoint kana kunze kwejoint bursa.
Kuratidzwa kwakadzika
Nzira ye percutaneous suprapatellar inoitwa nekuparadzanisa tendon ye quadriceps kwenguva refu kusvika pakatsemuka pakwana nzira yekufambisa zvishandiso zvakaita sezvipikiri zve intramedullary. Nzira ye parapatellar ligament, iyo inopfuura pedyo netsandanyama ye quadriceps, inogonawo kuratidzwa kune nzira ye tibial intramedullary nail. Tsono ye trocar isina kusimba uye cannula zvinopfuudzwa nokungwarira kuburikidza ne patellofemoral joint, nzira inotungamira nzvimbo yekupinda ye anterior-superior ye tibial intramedullary nail kuburikidza ne femoral trocar. Kana trocar yaiswa panzvimbo kwayo, inofanira kusimbiswa kuti isakuvadze cartilage yebvi.
Nzira huru yekucheka ganda inogona kushandiswa pamwe chete ne hyperextension parapatellar skin incision, pamwe nenzira ye medial kana lateral. Kunyangwe vamwe vanachiremba vasingachengetedze bursa isina kukuvadzwa panguva yekuvhiyiwa, Kubiak nevamwe vanotenda kuti bursa inofanira kuchengetedzwa isina kukuvadzwa uye zvivakwa zvekunze kwemuviri zvinofanira kuratidzwa zvakanaka. Mupfungwa, izvi zvinopa dziviriro yakanaka yegumbo uye zvinodzivirira kukuvara kwakadai sehutachiona hwemabvi.
Maitiro atsanangurwa pamusoro apa anosanganisirawo kupatsanurwa kwepatella, izvo zvinoderedza kumanikidzwa kwekubatana panzvimbo dzakanangana kusvika pamwero wakati. Kana zvakaoma kuita ongororo yepatellofemoral joint nekaburi kadiki kemajoini uye mudziyo wekuwedzera mabvi wakaganhurirwa zvakanyanya, vanyori vanokurudzira kuti patella inogona kupatsanurwa zvishoma nekupatsanurwa kwemajoini. Kuchekwa kwepakati kwepakati, kune rumwe rutivi, kunodzivirira kukuvara kwemajoini anotsigira, asi zvakaoma kuita kugadzirisa kukuvara kwebvi zvinobudirira.
Nzvimbo yekupinda netsono yeSPN yakafanana neye infrapatellar approach. Anterior nelateral fluoroscopy panguva yekuisa tsono inoita kuti nzvimbo yekuisa tsono ive yakarurama. Chiremba anofanira kuona kuti tsono inotungamira haisundirwe kure zvakanyanya kumashure mu proximal tibia. Kana ikasundirwa zvakanyanya kumashure, inofanira kuiswazve nerubatsiro rwembambo inovhara pasi pe posterior coronal fluoroscopy. Pamusoro pezvo, Eastman nevamwe vanotenda kuti kuboora pini yekupinda munzvimbo yebvi yakapfava kunobatsira pakudzoreredza kutyoka panzvimbo yakatambanudzwa.
Zvishandiso zvekuderedza
Zvishandiso zvinoshanda zvekuderedza zvinosanganisira maforceps ekuderedza pfungwa ane saizi dzakasiyana, mafemoral lifters, zvishandiso zvekugadzirisa zvekunze, uye mafixator emukati ekugadzirisa zvidimbu zvidiki zvakatyoka neplate imwe chete yecortical. Zvipikiri zvinovhara zvinogona kushandiswawo pakuderedza kwataurwa pamusoro apa. Nyundo dzekuderedza dzinoshandiswa kugadzirisa sagittal angulation uye transverse displacement deformities.
Zvigadzirwa zvemuviri
Vagadziri vazhinji vema "orthopedic internal fixators" vakagadzira masisitimu ekushandisa ane michina inotungamira kuiswa kwezvipikiri zve "tibial intramedullary". Izvi zvinosanganisira ruoko rwakatambanudzwa, mudziyo wekuyera urefu hwepini, uye "medullary expander". Zvakakosha kuti "trocar" nema "blunt trocar pins" zvidzivirire zvakanaka kupinda kwezvipikiri zve "intramedullary". Chiremba anofanira kusimbisazve nzvimbo ye "cannula" kuitira kuti kukuvara kwe "patellofemoral joint" kana "periarticular structures" kusaitike nekuda kwekuva pedyo zvakanyanya ne "driving device".
Zvikuruu zveKukiya
Chiremba anofanira kuona kuti huwandu hwakakwana hwemasikuruu anokiya aiswa kuti arambe achideredza zvinogutsa. Kugadzirisa zvidimbu zvidiki zvemakumbo (proximal kana distal) kunoitwa nemasikuruu matatu kana kupfuura anokiya pakati pezvidimbu zvemakumbo zviri pedyo, kana nemasikuruu ane angle yakatarwa chete. Nzira yepamusoro penzira yetibial intramedullary nail yakafanana nenzira ye infrapatellar maererano nehunyanzvi hwekutyaira masikuruu. Masikuruu anokiya anofambiswa nemazvo pasi pe fluoroscopy.
Kuvharwa kweronda
Kusveta nechikamu chekunze chakakodzera panguva yekukurisa kunobvisa zvidimbu zvemapfupa zvisina kuchena. Maronda ese anofanira kudirwa zvakanaka, kunyanya panzvimbo yekuvhiyiwa kwebvi. Katsi yemakumbo kana ligament layer pamwe ne suture panzvimbo yakatsemuka zvinozovharwa, zvichiteverwa nekuvhara kwedermis neganda.
Kubviswa kwembambo yemukati memedullary
Kana chipikiri chemukati memudullary chinoroverwa kuburikidza nenzira yepamusoro-soro chingabviswa kuburikidza nenzira yekuvhiya yakasiyana chichiri kukakavadzana. Nzira inonyanya kushandiswa ndeye transarticular suprapatellar nzira yekubvisa chipikiri mukati memudullary. Nzira iyi inofumura chipikiri nekuboorera kuburikidza nenzira yepamusoro-soro yemudullary uchishandisa chibooreso che 5.5 mm chisina chinhu. Chishandiso chekubvisa chipikiri chinozofambiswa kuburikidza nenzira iyi, asi maneuverance iyi inogona kuoma. Nzira dzeparapatellar ne infrapatellar inzira dzakasiyana dzekubvisa chipikiri mukati memudullary.
Njodzi Njodzi dzekuvhiyiwa kwesuprapatellar approach kune tibial intramedullary nail technique dzinosanganisira kukuvara kwepatella nefemoral talus cartilage, kukuvara kwevamwe maumbirwo emukati mearticular, hutachiona hwemajoini, uye tsvina yemukati mearticular. Zvisinei, hapana mishumo yekiriniki inoenderana. Varwere vane chondromalacia vachanyanya kukuvara necartilage inokonzerwa nemishonga. Kukuvadzwa kwepatellar nefemoral articular surface structures chinhu chinonyanya kunetsa vanachiremba vanoshandisa nzira iyi yekuvhiya, kunyanya nzira ye transarticular.
Kusvika pari zvino, hapana humbowo hwekuongorora hunoratidza zvakanakira nekuipira kwenzira yekuvhiya nzara ye semi-extension tibial intramedullary.
Nguva yekutumira: Gumiguru-23-2023
