I-malunion ye-Navicular ivela malunga ne-5-15% yazo zonke iifractures ezibukhali zethambo le-navicular, kunye ne-necrosis ye-navicular eyenzeka malunga ne-3%. Imiba yomngcipheko we-malunion ye-navicular ibandakanya ukuxilongwa okuphosiweyo okanye ukulibaziseka, ukusondela komgca we-fracture, ukufuduka okukhulu kune-1 mm, kunye nokuphuka ngokungazinzi kwe-carpal. Ukuba ishiywe ingaphendulwanga, i-osteochondral nonunion ye-navicular ihlala ihambelana nesifo samathambo, eyaziwa ngokuba yi-navicular osteochondral nonunion kunye ne-osteoarthritis yokuwa.
Ukuxutywa kwethambo kunye okanye ngaphandle kwe-vascularised flap kungasetyenziselwa ukuphatha i-osteochondral nonunion ye-navicular. Nangona kunjalo, kwizigulane ezine-osteonecrosis ye-proximal pole ye-navicular bone, iziphumo ze-bone grafting ngaphandle kwe-vascular tip ayinelisekanga, kwaye izinga lokuphulukisa amathambo li-40% -67 kuphela. Ngokwahlukileyo, izinga lokuphulukiswa kwamathambo amathambo ane-vascularised flaps ingaba phezulu kwi-88% -91%. Awona mathambo aphambili anevascularised kuqheliselo lweklinikhi abandakanya i-1,2-ICSRA-tipped distal radius flap, uxhulumaniso lwethambo + implanti yemithambo yemithambo, i-palmar radius flap, i-flap yethambo ye-iliac yasimahla enencam ye-vascularised, kunye ne-medial femoral condylar bone flap (MFC VBG), njl I-MFC VBG yamahhala ibonakaliswe ukuba iyasebenza kunyango lwe-navicular fractures kunye ne-metacarpal collapse, kwaye i-MFC VBG isebenzisa isebe le-articular ye-articular knee ehla njengesebe eliphambili le-trophic. Xa kuthelekiswa nezinye iiflephu, i-MFC VBG inikezela ngenkxaso eyaneleyo yesakhiwo ukubuyisela imilo eqhelekileyo yethambo le-navicular, ngokukodwa kwi-navicular fracture osteochondrosis ene-bowed back deformity (Umfanekiso 1). Kunyango lwe-osteochondral osteonecrosis ye-navicular nge-progressive carpal collapse, i-1,2-ICSRA-tipped distal radius flap kuye kwabikwa ukuba inomlinganiselo wokuphulukisa amathambo we-40% kuphela, kanti i-MFC VBG inezinga lokuphulukisa amathambo e-100%.
Umzobo 1. Ukuphulwa kwethambo le-navicular kunye ne-"bowed back" deformity, i-CT ibonisa ibhloko yokuphuka phakathi kwamathambo e-navicular kwi-angle malunga ne-90 °.
Ukulungiselela kwangaphambili
Emva kokuhlolwa komzimba wesandla esichaphazelekayo, izifundo zokucinga kufuneka zenziwe ukuvavanya iqondo lokuwa kwesandla. I-radiographs ecacileyo iluncedo ekuqinisekiseni indawo yokuphuka, iqondo lokufuduka, kunye nobukho be-resorption okanye i-sclerosis yesiphelo esaphukileyo. Imifanekiso yangaphambili yangasemva isetyenziselwa ukuvavanya ukuwa kwesihlahla, ukungazinzi komqolo wesihlahla (DISI) kusetyenziswa umlinganiselo olungisiweyo wokuphakama kwesihlahla (ubude/ububanzi) be-≤1.52 okanye i-radial lunate angle engaphezu kwe-15 °. I-MRI okanye i-CT inokunceda ukuxilonga ukungahambi kakuhle kwethambo le-navicular okanye i-osteonecrosis. I-radiographs ye-Lateral okanye i-oblique sagittal CT ye-navicular bone ene-navicular angle> 45 ° iphakamisa ukunciphisa ithambo le-navicular, eyaziwa ngokuba "yi-bowed back deformity". akukho kubaluleka okucacileyo ekunqumeni ukuphiliswa kokwaphuka.
Iimpawu kunye ne-contraindications:
I-Navicular osteochondral nonunion kunye ne-back back deformity kunye ne-DISI; I-MRI ibonisa i-ischemic necrosis yethambo le-navicular, i-intraoperative ukukhulula i-tourniquet kunye nokubonwa kwe-fracture ephukile ekupheleni kwethambo le-navicular kusese-white sclerotic bone; ukusilela kokuxhunyelelwa kwethambo lokuqala lewedge okanye ukulungiswa kwangaphakathi kufuna iVGB enkulu yolwakhiwo lwamathambo (＞1cm3). ukufunyaniswa kwangaphambili okanye kwi-intraoperative ye-osteoarthritis ye-radial carpal joint; ukuba i-malunion ebalulekileyo ye-navicular kunye ne-osteoarthritis yokuwa yenzekile, ngoko ke ukuchithwa kwesandla, i-osteotomy ye-navicular, i-fusion ye-quadrangular, i-proximal carpal osteotomy, i-carpal fusion iyonke, njl., inokufuneka; i-malunion ye-navicular, i-necrosis esondeleyo, kodwa kunye ne-morphology ye-navicular bone morphology (umzekelo, i-non-displaced navicular fracture kunye nonikezelo lwegazi olubi kwi-pole proximal); ukunciphisa i-malunion ye-navicular ngaphandle kwe-osteonecrosis. (I-1,2-ICSRA ingasetyenziselwa indawo ye-distal radius flap).
I-Anatomy esetyenzisiweyo
I-MFC VBG ibonelelwa ngenani leenqanawa ezincinci ze-trophoblastic (zithetha i-30, i-20-50), kunye neyona nto ininzi yegazi ingaphantsi kwe-condyle ye-femoral ephakathi (ithetha i-6.4), ilandelwa yi-anteriorly superior (ithetha i-4.9) ( Umzobo 2). Ezi zitya ze-trophoblastic zazibonelelwa ikakhulu yi-articular geniculate artery (DGA) kunye/okanye i-medial medial geniculate artery (SMGA), eyisebe le-artery ye-femoral engaphezulu ebangela ukuba i-articular, musculocutaneous, kunye / okanye i-saphenous nerve amasebe. . i-DGA yavela kwi-artery ye-femoral engaphezulu ukuya kwi-medial eminence ye-medial malleolus, okanye kumgama we-13.7 cm esondele kumphezulu we-articular (10.5-17.5 cm), kwaye ukuzinza kwe-branching kwakuyi-89% kwimizekelo ye-cadaveric (Umfanekiso 3). I-DGA ivela kwi-artery ye-femoral engaphezulu kwi-13.7 cm (10.5 cm-17.5 cm) esondele kwi-fissure ye-malleolus ephakathi okanye i-proximal kumphezulu we-articular, kunye ne-cadaveric specimen ebonisa i-100% ukuzinza kwe-branching kunye nobubanzi obumalunga ne-0.78 mm. Ngoko ke, mhlawumbi i-DGA okanye i-SMGA iyamkeleka, nangona yangaphambili ifaneleka ngakumbi kwi-tibiae ngenxa yobude kunye nobubanzi bomkhumbi.
Umzobo 2. Ukuhanjiswa kwee-quadrant ezine ze-MFC ze-trophoblast iinqanawa kunye nomgca onqamlekileyo phakathi kwe-semitendinosus kunye ne-medial collateral ligament A, umgca we-trochanter enkulu ye-B, umgca wesigxina esiphezulu se-patella C, umgca we-meniscus D yangaphambili.
Umzobo 3. I-MFC vascular anatomy: (A) Amasebe angaphezulu kunye ne-MFC trophoblastic vascular anatomy, (B) Umgama wemvelaphi ye-vascular ukusuka kumgca odibeneyo
Ufikelelo ngotyando
Isigulane sibekwe phantsi kwe-anesthesia jikelele kwindawo ye-supine, kunye nelungu elichaphazelekayo libekwe kwitafile yokuhlinzwa yesandla. Ngokuqhelekileyo, i-flap bone ye-donor ithathwa kwi-condyle ye-femoral ye-ipsilateral medial, ukwenzela ukuba isigulane sikwazi ukuhamba ngeentonga emva kokuhlinzwa. Idolo elichasayo lingakhethwa kwakhona ukuba kukho imbali yentlungu yangaphambili okanye utyando kwicala elifanayo ledolo. Idolo liguquguqukayo kwaye i-hip ijikelezwe ngaphandle, kwaye i-tourniquets isetyenziswe kuzo zombini iindawo eziphezulu kunye nezantsi. Indlela yotyando yayiyindlela eyandisiweyo yaseRusse, kunye ne-8 cm yokusika esondele kwitonela ye-carpal enqamlezayo kwaye isuka kude ukusuka kumda we-radial flexor carpi radialis tendon, kwaye emva koko isonga kwitonela ye-carpal enqamlezayo ukuya kwisiseko sesithupha. , ephela kwinqanaba le-trochanter enkulu. I-tendon sheath ye-radial longissimus tendon ihlanjululwe kwaye i-tendon itsalwa ngokungafaniyo, kwaye ithambo le-navicular libonakaliswe ngokuchithwa okubukhali kunye ne-radial lunate kunye ne-radial navicular head ligaments, ngokuhlukana ngokucophelela kwe-peripheral soft tissues ye-navicular bone ukuvumela. ukuvezwa ngakumbi kwethambo le-navicular (Umfanekiso 4). Qinisekisa ummandla we-nonunion, umgangatho we-articular cartilage kunye neqondo le-ischemia yethambo le-navicular. Emva kokukhulula i-tourniquet, jonga i-proximal pole ye-navicular bone yokuphuma kwegazi ukuze ubone ukuba kukho necrosis ye-ischemic. Ukuba i-necrosis ye-navicular ayihambelani ne-radial carpal okanye i-intercarpal arthritis, i-MFC VGB ingasetyenziswa.
Umzobo 4. Indlela yotyando lwe-Navicular: (A) I-incision iqala i-8 cm esondele kwitonela ye-carpal enqamlezayo kwaye yandisa umda we-radial we-radial flexor carpi radialis tendon ukuya kwindawo ekude ye-incision, egoqwe ngokubhekiselele kwisiseko sesithupha. kwitonela ye-carpal enqamlezileyo. (B) I-tendon sheath ye-tendon ye-radial longissimus incised kwaye i-tendon itsalwa ulnarly, kwaye ithambo le-navicular libonakaliswe ngokuchithwa okubukhali kunye ne-radial lunate kunye ne-radial navicular head ligaments. (C) Chonga indawo ye-navicular osseous discontinuity.
I-15-20 cm ubude be-incision yenziwe i-proximal ukuya kumgca odibeneyo wedolo ecaleni komda ongasemva we-femoral muscle, kwaye i-muscle ihoxiswa ngaphambili ukuze iveze unikezelo lwegazi lwe-MFC (umzobo 5) . ngamasebe e-articular ye-DGA kunye ne-SMGA, ngokuqhelekileyo ithatha isebe elikhulu elihlangeneyo le-DGA kunye ne-vein ehambelanayo. I-vascular pedicle ikhululwe ngokusondeleyo, inakekele ukukhusela i-periosteum kunye neenqanawa ze-trophoblastic kwi-bony surface.
Umzobo 5. Ukufikelela ngokuhlinzwa kwi-MFC: (A) I-15-20 cm ubude be-incision yenziwe ngokusondeleyo kumda ongasemva we-medial femoral muscle ukusuka kumgca ohlangeneyo wamadolo. (B) Isihlunu sibuyiselwe phambili ukuze siveze unikezelo lwegazi lwe-MFC.
Ukulungiswa kwethambo le-navicular
I-navicular DISI deformity kufuneka ilungiswe kwaye indawo ye-osteochondral bone graft ilungiswe ngaphambi kokufakelwa ngokuguquguquka kwesandla phantsi kwe-fluoroscopy ukubuyisela i-angle ye-radial lunate yesiqhelo (Umfanekiso 6). I-0.0625-foot (malunga ne-1.5-mm) i-Kirschner pin ibhotywa nge-percutaneously ukusuka kwi-dorsal ukuya kwi-metacarpal ukulungisa i-radial lunate joint, kunye ne-navicular malunion gap ibonakaliswe xa isihlahla silungiswa. Isithuba sokuqhekeka sacocwa kwiithishu ezithambileyo kwaye savulwa ngakumbi ngesisasaza sepleyiti. Isarha encinci yokubuyisela isetyenziselwa ukucaba ithambo kunye nokuqinisekisa ukuba i-flap yokufakelwa ifana nesakhiwo soxande kune-wedge, efuna ukuba i-gap ye-navicular iphathwe nge-gap ebanzi kwicala le-palmar kunakwicala le-dorsal. Emva kokuvula i-gap, i-defect ilinganiswa kwimilinganiselo emithathu ukucacisa ubungakanani bethambo lethambo, elihlala li-10-12 mm ubude kumacala onke.
Umzobo 6. Ukulungiswa kwe-back back deformity ye-navicular, kunye ne-fluoroscopic flexion of wrist ukubuyisela ukulungelelaniswa okuqhelekileyo kwe-radial-lunar. I-0.0625-foot (malunga ne-1.5-mm) i-Kirschner pin ibhobhoza i-percutaneously ukusuka kwi-dorsal ukuya kwi-metacarpal ukulungisa i-radial lunate joint, ukuveza i-gap malunion ye-navicular kunye nokubuyisela ukuphakama okuqhelekileyo kwethambo le-navicular xa isandla silungiswa, kunye nobukhulu becala. Isikhewu esiqikelela ubungakanani beflap ekuya kufuneka ukuba ikhawulwe.
I-Osteotomy
Ummandla we-vascularized of the medial femoral condyle ukhethwa njengendawo yokukhutshwa kwamathambo, kwaye indawo yokukhutshwa kwamathambo iphawulwe ngokwaneleyo. Qaphela ukuba ungalimazi i-medial collateral ligament. I-periosteum incised, kunye ne-rectangular bone flap yobukhulu obufanelekileyo kwi-flap efunwayo iyasikwa kunye ne-saw reciprocating, kunye ne-bone ibhloko yesibini enqunywe kwi-45 ° ecaleni kwelinye ukuze kuqinisekiswe ukunyaniseka kwe-flap (umzobo 7). 7). Ukunyamekela kufuneka kuthathwe ukuba ungahluli i-periosteum, i-cortical bone, kunye nethambo lokukhansela le-flap. I-tourniquet engezantsi kufuneka ikhutshwe ukuze ibone ukuhamba kwegazi kwi-flap, kwaye i-vascular pedicle kufuneka ikhululwe ngokusondeleyo ubuncinane ubuncinane be-6 cm ukuvumela i-anastomosis ye-vascular elandelayo. Ukuba kuyimfuneko, inani elincinci lethambo lokukhansela lingaqhutyelwa ngaphakathi kwe-condyle ye-femal. I-femoral condylar defect izaliswe nge-bone graft substitute, kwaye i-incision ikhutshwe kwaye ivalwe umaleko.
Umzobo 7. Ukususwa kweflap yethambo le-MFC. (A) Indawo ye-osteotomy eyaneleyo yokuzalisa indawo ye-navicular iphawulwe, i-periosteum ihlanjululwe, kunye ne-rectangular bone flap yobukhulu obufanelekileyo be-flap efunwayo iyasikwa ngesarha ebuyiselayo. (B) Isiqwenga sesibini sethambo sinqunywe kwicala elinye kwi-45 ° ukuqinisekisa ukunyaniseka kwe-flap.
I-Flap implantation kunye nokulungiswa
I-flap yamathambo inqunywe kwimilo efanelekileyo, inakekele ukuba ungayicinezeli i-vascular pedicle okanye i-periosteum. I-flap ifakwe ngobunono kwindawo ye-navicular bone defect, ukuphepha i-percussion, kwaye igxininiswe nge-screws ye-navicular. Kwathathwa unonophelo ukuze kuqinisekiswe ukuba umda wepalmar yebloko yethambo efakiweyo igungxulwe ngomda wepalmar yethambo le-navicular okanye ukuba ibidakumbile kancinci ukunqanda ukufakwa. I-Fluoroscopy yenzelwe ukuqinisekisa i-navicular bone morphology, umgca wamandla kunye ne-screw position. I-Anastomose i-vascular flap artery ukuya kwi-radial artery ekupheleni ukuya kwicala kunye nencam ye-venous ukuya kwi-radial artery companion vein end to end (Figure 8). I-capsule edibeneyo iyalungiswa, kodwa i-vascular pedicle iyagwenywa.
Umzobo 8. Ukufakelwa kwe-flap ye-Bone, ukulungiswa, kunye ne-anastomosis ye-vascular. I-flap yethambo ifakwe ngobumnene kwindawo ye-navicular bone defect kwaye ilungiswe ngee-screws ze-navicular ezingenanto okanye izikhonkwane ze-Kirschner. Inkathalo ithathwa ukuba umda we-metacarpal webloko yethambo efakiweyo igungxulwe ngomda we-metacarpal wethambo le-navicular okanye ucinezeleke kancinci ukuphepha ukunyanzeliswa. I-Anastomosis ye-vascular flap artery ukuya kwi-radial artery yenziwa ekupheleni ukuya ekupheleni, kwaye i-vein tip kwi-radial artery companion vein yenziwa ekupheleni ukuya ekupheleni.
Ukuvuselelwa emva kokuhlinzwa
I-aspirin yomlomo i-325 mg ngosuku (kwinyanga ye-1), ukuthwala ubunzima be-postoperative yelungu elichaphazelekayo livunyelwe, ukunyanyiswa kwamadolo kunokunciphisa ukungahambi kakuhle kwesigulane, kuxhomekeke kwikhono lomguli ukuhamba ngexesha elifanelekileyo. Ukuxhaswa kwe-Contralateral ye-crutch eyodwa kunokunciphisa intlungu, kodwa ukuxhaswa kwexesha elide leentonga akuyimfuneko. Izithungo zasuswa kwiiveki ezi-2 emva kotyando kwaye i-Muenster okanye ingalo ende ukuya kwisithupha yagcinwa kwindawo yeeveki ezi-3. Emva koko, ingalo emfutshane ukuya kubhontsi isetyenzisiwe de i-fracture iphile. I-X-rays ithathwa kwiiveki ze-3-6, kwaye ukuphulukiswa kwe-fracture kuqinisekiswa yi-CT. Emva koko, i-flexion esebenzayo kunye ne-passive flexion kunye nemisebenzi yokwandisa kufuneka iqalwe ngokuthe ngcembe, kwaye ukuqina kunye nokuphindaphinda komthambo kufuneka kwandiswe ngokuthe ngcembe.
Iingxaki ezinkulu
Iingxaki eziphambili zedolo edibeneyo ziquka intlungu yedolo okanye ukulimala kwe-nerve. Iintlungu zedolo zenzeke ngokukodwa kwiiveki ze-6 emva kokuhlinzwa, kwaye akukho kulahlekelwa kwemvakalelo okanye i-neuroma ebuhlungu ngenxa yokulimala kwe-nerve ye-saphenous yafunyanwa. Iingxaki eziphambili zesihlahla zibandakanya ukungahambi kwamathambo, iintlungu, ukuqina kwamalungu, ubuthathaka, i-osteoarthritis eqhubekayo ye-radial wrist okanye amathambo e-intercarpal, kunye nomngcipheko we-periosteal heterotopic ossification nayo ixeliwe.
I-Free Medial Femoral Condyle Vascularised Bone Grafting ye-Scaphoid Nonunions kunye ne-Proximal Pole Avascular Necrosis kunye neCarpal Collapse
Ixesha lokuposa: May-28-2024
