Iyo suprapatellar nzira ndiyo yakagadziridzwa nzira yekuvhiya yetibial intramedullary mbambo mune semi-yakawedzerwa ibvi chinzvimbo.Pane zvakawanda zvakanakira, asiwo zvakaipira, kuita intramedullary chipikiri chetibia kuburikidza ne suprapatellar nzira muhallux valgus chinzvimbo.Vamwe vanachiremba vanovhiya vakajaira kushandisa SPN kurapa zvese tibial fractures kunze kwekuwedzera-articular fractures ye proximal 1/3 yetibia.
Zviratidzo zveSPN ndezvi:
1. Kuputsika kana segmental fractures yetibial stem.2;
2. kuputsika kwe distal tibial metaphysis;
3. kuputsika kwehudyu kana ibvi nekugadziriswa kusati kwavapo (semuenzaniso, kuparara kwehudyu yekubatana kana fusion, osteoarthritis yemabvi) kana kusakwanisa kushandura mabvi kana chiuno (semuenzaniso, kuparara kwemashure kwehudyu, kuputsika kwepsilateral. femur);
4. tibial fracture yakasanganiswa nekukuvara kweganda pane infrapatellar tendon;
5. kutsemuka kwetibial mumurwere ane chidimbu chakareba chakareba (kusvika kwekupedzisira kwetibia kunowanzooma kuona pasi pe fluoroscopy apo kureba kwetibia kunodarika urefu hwetatu iyo fluoroscopy inogona kupfuura).
Kubatsira kwehafu-yakawedzerwa nzvimbo yemabvi tibial intramedullary nail technique yekurapa kwepakati-tibial diaphysis uye distal tibial fractures iri mukureruka kwekugadzirisa uye nyore kwefluoroscopy.Iyi nzira inobvumira kutsigirwa kwakanakisisa kwehurefu hwakazara hwetibia uye nyore sagittal kuderedzwa kwekuputsika pasina kudiwa kwekugadzirisa (Mifananidzo 1, 2).Izvi zvinobvisa kudiwa kwemubatsiri akadzidziswa kuti abatsire ne intramedullary nail technique.
Mufananidzo 1: Chimiro chechimiro che intramedullary nail technique ye infrapatellar approach: ibvi iri munzvimbo yakagadzikana pane fluoroscopically penetrable tripod.Nekudaro, chinzvimbo ichi chinogona kuwedzera kurongeka kwakashata kweiyo fracture block uye inoda mamwe maitiro ekudzikisa ekuderedza kuputsika.
Mufananidzo 2: Kusiyana neizvi, nzvimbo yakatambanudzwa ibvi pane rampu yefuro inogonesa kurongeka kwevhavha uye kutevedzera kunotevera.
Kuvhiya Techniques
Tafura / Chinzvimbo Murwere akarara panzvimbo yekumusoro pamubhedha wefluoroscopic.Lower extremity traction inogona kuitwa, asi haifaniri.The Vascular table inonyatsokodzera suprapatellar approach tibial intramedullary nail, asi hazvidiwi.Zvisinei, mibhedha yakawanda yekuputsika kana mibhedha yefluoroscopic haina kukurudzirwa sezvo isina kukodzera suprapatellar nzira yetibial intramedullary nail.
Padding iyo ipsilateral chidya inobatsira kuchengetedza chikamu chepasi munzvimbo yakatenderedzwa kunze.Ramp isina furo rinobva rashandiswa kusimudza nhengo yakabatwa pamusoro pedivi re contralateral for posterolateral fluoroscopy, uye nzvimbo yakachinjika yehudyu nemabvi inobatsirawo mukutungamirira pini uye intramedullary chipikiri.Iyo yakakwana ibvi yekuchinjika angle ichiri gakava, naBeltran et al.ichikurudzira kuchinjika kwebvi 10° uye Kubiak achikurudzira kuchinjika kwebvi 30°.Nyanzvi zhinji dzinobvuma kuti mabvi anochinjika makona mukati mezvikamu izvi zvinogamuchirwa.
Zvisinei, Eastman et al.akawana kuti sezvo mabvi ekutenderera kwekona akawedzera zvishoma nezvishoma kubva ku10 ° kusvika ku50 °, mhedzisiro yefemoral talon pa percutaneous penetration yechiridzwa yakaderedzwa.Naizvozvo, ibvi rakakura rekuchinjika kona rinobatsira mukusarudza iyo chaiyo intramedullary chipikiri yekupinda chinzvimbo uye kugadzirisa angular deformities mu sagittal plane.
Fluoroscopy
Muchina weC-arm unofanirwa kuiswa kune rumwe rutivi rwetafura kubva kunhengo yakabatwa, uye kana chiremba anovhiya akamira padivi pebvi rinenge rabatwa, mucherechedzo unofanirwa kunge uri pamusoro pemushini weC-arm uye pedyo. .Izvi zvinobvumira chiremba wekuvhiya uye radiologist kuti aone nyore cheki, kunze kwekunge mbambo yedistal yakavharika ichapinzwa.Kunyangwe zvisiri zvekusungirwa, vanyori vanokurudzira kuti C-ruoko rwufambiswe kudivi rimwe chete uye chiremba anovhiya kune rimwe divi kana medial interlocking screw ichafambiswa.Neimwe nzira, muchina weC-ruoko unofanirwa kuiswa parutivi rwakakanganisika apo chiremba anovhiya anoita maitiro kune contralateral side (Mufananidzo 3).Iyi ndiyo nzira inonyanya kushandiswa nevanyori nekuti inodzivirira kudiwa kwechiremba anovhiya kubva kudivi remukati kuenda kune lateral side kana uchityaira distal locking chipikiri.
Mufananidzo 3: Chiremba anovhiya anomira kune rumwe rutivi rwetibia yakakanganiswa kuitira kuti medial interlocking screw inogona kutyaira nyore nyore.Chiratidziro chiri pakatarisana nachiremba anovhiya, kumusoro kweC-ruoko.
Zvose anteroposterior uye medial-lateral fluoroscopic maonero anowanikwa pasina kufambisa nhengo yakakanganiswa.Izvi zvinodzivirira kutamiswa kwenzvimbo yekuputsika iyo yakagadziridzwa zvakare kutsemuka kusati kwanyatsogadziriswa.Mukuwedzera, mifananidzo yehurefu hwakazara hwetibia inogona kuwanikwa pasina kurerekera C-ruoko nenzira inotsanangurwa pamusoro apa.
Kuchekwa kweganda Machekwa ese akaganhurirwa uye akawedzerwa zvakafanira akakodzera.Iyo percutaneous suprapatellar nzira ye intramedullary nail inobva pakushandiswa kwe 3-cm incision kurovera mbambo.Zvizhinji zvezvipembenene izvi zvekuvhiya ndezvekureba, asi zvinogonawo kutenderera, sezvakakurudzirwa naDr. Morandi, uye kuwedzerwa kwakawedzerwa kushandiswa naDr. Tornetta nevamwe kunoratidzwa kune varwere vane patellar subluxation yakabatanidzwa, avo vane parapatellar yakawanda yepakati kana lateral. kusvika.Mufananidzo 4 unoratidza maitiro akasiyana.
Mufananidzo 4: Mufananidzo wemaitiro akasiyana-siyana ekuvhiya.1- Suprapatellar transpatellar ligament approach;2- Parapatellar ligament nzira;3- Medial limited incision parapatellar ligament approach;4- Medial yakareba incision parapatellar ligament approach;5- Lateral parapatellar ligament nzira.Kuratidzwa kwakadzika kweparapatellar ligament approach kunogona kunge kuburikidza nekubatana kana kunze kwejojo bursa.
Kuratidzwa kwakadzama
Iyo percutaneous suprapatellar approach inoitwa kunyanya nekurebesa kuparadzanisa quadriceps tendon kusvikira gaka rinogona kugadzirisa nzira yezviridzwa zvakadai se intramedullary misumari.Iyo parapatellar ligament approach, iyo inopfuura pedyo ne quadriceps muscle, inogonawo kuratidzwa kune tibial intramedullary nail technique.A blunt trocar tsono uye cannula zvakanyatsopfuura nepatellofemoral joint, nzira iyo inonyanya kutungamirira anterior-superior entry point ye tibial intramedullary nail nenzira ye femoral trocar.Kamwe iyo trocar yakanyatso kurongeka, inofanirwa kuchengetedzwa munzvimbo kuti irege kukuvara kune articular cartilage yemabvi.
Iyo yakakura transligamentous incision approach inogona kushandiswa pamwe chete ne hyperextension parapatellar skin incision, pamwe nepakati kana lateral nzira.Kunyange zvazvo vamwe vanachiremba vasingachengetedze bursa intact intraoperative, Kubiak et al.tenda kuti bursa inofanirwa kuchengetedzwa yakasimba uye zvimiro zvekuwedzera-articular zvinofanirwa kuburitswa pachena.Nechepfungwa, izvi zvinopa kudzivirira kwakanakisa kwemabvi akabatana uye kunodzivirira kukuvadzwa kwakadai sehutachiona hwemabvi.
Nzira inotsanangurwa pamusoro apa inosanganisirawo hemi-dislocation yepatella, iyo inoderedza kushamwaridzana kwehutano pane articular surfaces kune imwe nzvimbo.Kana zvakaoma kuita patellofemoral joint assessment nediki diki mhango uye yakanyanya kuderedzwa mabvi ekuwedzera mudziyo, vanyori vanokurudzira kuti patella inogona semi-dislocated nekuparadzaniswa kwe ligament.Iyo yepakati transverse incision, kune rumwe rutivi, inodzivirira kukuvadzwa kune anotsigira ligaments, asi zvakaoma kuita inobudirira kukuvara kwemabvi kugadzirisa.
Iyo SPN tsono yekupinda poindi yakafanana neyeiyo infrapatellar nzira.Anterior uye lateral fluoroscopy panguva yekupinza tsono inova nechokwadi chekuti tsono yekupinza point ndeyechokwadi.Chiremba anovhiya anofanirwa kuve nechokwadi chekuti tsono inotungamira haifambisirwe kure kure kumashure mukati meiyo proximal tibia.Kana iyo inotyairwa zvakanyanya zvakadzika shure, inofanira kuiswa zvakare nerubatsiro rwechipikiri chinovhara pasi pemashure coronal fluoroscopy.Mukuwedzera, Eastman et al.tenda kuti kudhirowa pini yekupinda mune inodudzwa yakachinjika ibvi chinzvimbo zvinobatsira mune inotevera kutsemuka repositioning mune hyperextended chinzvimbo.
Zvishandiso zvekudzikisa
Zvishandiso zvinoshanda zvekudzikisa zvinosanganisira mapoinzi ekudzikisa masimba ehukuru hwakasiyana, zvekusimudza femoral, ekunze zvigadziriso zvekugadzirisa, uye zvigadziriso zvemukati zvekugadzirisa zvimedu zvidiki zvekutyoka nendiro yecortical imwe chete.Kuvhara zvipikiri kunogonawo kushandiswa kune yakataurwa pamusoro pekudzikisa maitiro.Sando dzekudzikisa dzinoshandiswa kugadzirisa sagittal angulation uye transverse displacement deformities.
Implants
Vazhinji vagadziri vemapfupa emukati mekugadzirisa magadzirirwo vakagadzira zvishandiso zvekushandisa masisitimu kutungamira kuiswa kwakajairwa kwetibial intramedullary misumari.Inosanganisira ruoko rwakatambanudzwa rwakasimudzwa, inotungamirwa pini yekuyera kureba mudziyo, uye medullary expander.Izvo zvakakosha kuti trocar uye blunt trocar pini dzidzivirire intramedullary chipikiri kuwana zvakanaka.Chiremba anovhiya anofanira kusimbisazve nzvimbo ye cannula kuitira kuti kukuvadzwa kwepatellofemoral joint kana periarticular structures nekuda kwekunyanya kuswedera pedyo nechigadzirwa chekutyaira chisingaiti.
Locking Screws
Chiremba anovhiya anofanirwa kuve nechokwadi chekuti nhamba yakakwana yezvivharo zvekukiya zvakaiswa kuti zvichengetedze kudzikiswa kunogutsa.Kugadziriswa kwezvimedu zvidiki zvakatyoka (proximal kana distal) kunoitwa ne3 kana kupfuura zvekukiya masiruu pakati pezvimedu zvepadhuze zvakatyoka, kana nemafikisi-angle screws ega.Iyo suprapatellar nzira yetibial intramedullary nail technique yakafanana neye infrapatellar nzira maererano nescrew driving technique.Locking screws anonyanya kufambiswa pasi pe fluoroscopy.
Kuvharwa kwemaronda
Kusveta nekasi yekunze kwakakodzera panguva yedilatation kunobvisa zvidimbu zvemapfupa emahara.Maronda ose anoda kunyatsodiridzwa, kunyanya nzvimbo yekuvhiya ibvi.Iyo quadriceps tendon kana ligament layer uye suture panzvimbo yekuputika inobva yavharwa, inoteverwa nekuvharwa kwedermis uye ganda.
Kubviswa kwembambo ye intramedullary
Pasinei nokuti tibial intramedullary nail inotungamirirwa nenzira ye suprapatellar inogona kubviswa kuburikidza nenzira yakasiyana yekuvhiya inoramba iine nharo.Nzira inonyanyozivikanwa ndeye transarticular suprapatellar nzira yekubvisa intramedullary mbambo.Iyi nzira inofumura mbambo nekuboora kuburikidza ne suprapatellar intramedullary nail channel uchishandisa 5.5 mm hollow drill.Chishandiso chekubvisa zvipikiri chinobva chafambiswa nemugero, asi kuita uku kunogona kunetsa.Iyo parapatellar uye infrapatellar nzira dzimwe nzira dzekubvisa intramedullary misumari.
Njodzi Njodzi dzekuvhiya dze suprapatellar nzira kune tibial intramedullary nail technique ndeyekukuvara kwehutano kune patella uye femoral talus cartilage, kukuvadzwa kwehutano kune mamwe maitiro e-intra-articular, hutachiona hwekubatana, uye intra-articular debris.Zvisinei, pane kushayikwa kwezvinyorwa zvekliniki zvinowirirana.Varwere vane chondromalacia vachave vakanyanya kutarisana nemishonga inokonzerwa nekukuvara kwecartilage.Kukuvadzwa kwekurapa kune patellar uye femoral articular pamusoro pezvimiro chinhu chinonyanya kunetsa kune vanovhiya vachishandisa nzira yekuvhiya iyi, kunyanya nzira yetransarticular.
Kusvika pari zvino, hapana humbowo hwekiriniki hwehuwandu hwezvakanakira uye zvakaipira semi-extension tibial intramedullary nail technique.
Nguva yekutumira: Oct-23-2023
