I-Navicular malunion yenzeka malunga ne-5-15% yazo zonke izaphuko ezibukhali zethambo le-navicular, kunye ne-navicular necrosis yenzeka malunga ne-3%. Izinto ezibangela umngcipheko we-navicular malunion ziquka ukuxilongwa okungaphoswanga okanye okulibazisekayo, ukusondela komgca wokuqhekeka, ukuhambahamba okungaphezulu kwe-1 mm, kunye nokuqhekeka okubangelwa kukungahlaliseki kwe-carpal. Ukuba ayinyangwa, i-navicular osteochondral nonunion idla ngokunxulunyaniswa ne-traumatic arthritis, eyaziwa ngokuba yi-navicular osteochondral nonunion ene-collapsing osteoarthritis.
Ukufakelwa kwamathambo nge-flap yemithambo okanye ngaphandle kwayo kungasetyenziselwa ukunyanga i-navicular osteochondral nonunion. Nangona kunjalo, kwizigulana ezine-osteonecrosis ye-proximal pole yethambo le-navicular, iziphumo zokufakelwa kwamathambo ngaphandle kwencam yemithambo azinelisi, kwaye izinga lokuphiliswa kwamathambo liyi-40%-67 kuphela. Ngokwahlukileyo koko, izinga lokuphiliswa kwamathambo nge-flaps yemithambo linokuba phezulu ukuya kwi-88%-91%. Ii-flaps zethambo eziphambili zemithambo kwizonyango ziquka i-1,2-ICSRA-tipped distal radius flap, i-bone graft + vascular bundle implant, i-palmar radius flap, i-free iliac bone flap ene-vascularised tip, kunye ne-medial femoral condylar bone flap (MFC VBG), njl. Iziphumo zokufakelwa kwamathambo nge-vascularised tip ziyanelisa. I-MFC VBG yamahhala ibonakalisiwe ukuba iyasebenza kunyango lwe-navicular fractures ene-metacarpal collapse, kwaye i-MFC VBG isebenzisa isebe le-articular le-descending knee artery njengesebe eliphambili le-trophic. Xa kuthelekiswa nezinye iiflaps, i-MFC VBG inika inkxaso eyaneleyo yolwakhiwo ukubuyisela imo eqhelekileyo yethambo le-navicular, ingakumbi kwi-navicular fracture osteochondrosis ene-bowed back deformity (Umfanekiso 1). Kunyango lwe-navicular osteochondral osteonecrosis ene-progressive carpal collapse, i-1,2-ICSRA-tipped distal radius flap ibikwe ukuba ine-bone healing rate ye-40% kuphela, ngelixa i-MFC VBG ine-bone healing rate ye-100%.
Umfanekiso 1. Ukwaphuka kwethambo le-navicular elinokukhubazeka "okugobile umqolo", i-CT ibonisa ibhloko yokuqhekeka phakathi kwamathambo e-navicular kwi-engile emalunga nama-90°.
Ukulungiselela ngaphambi kotyando
Emva kokuhlolwa ngokwasemzimbeni kwesandla esichaphazelekayo, kufuneka kwenziwe izifundo zomfanekiso ukuze kuvavanywe ubungakanani bokuqhekeka kwesandla. Ii-radiographs ezicacileyo ziluncedo ukuqinisekisa indawo yokwaphuka, ubungakanani bokushukuma, kunye nokuba khona kwe-resorption okanye i-sclerosis yesiphelo esiphukileyo. Imifanekiso engasemva yangaphambili isetyenziselwa ukuvavanya ukuqhekeka kwesandla, ukungazinzi kwesandla esingasemva (i-DISI) kusetyenziswa umlinganiselo wokuphakama kwesandla oguquliweyo (ubude/ububanzi) we-≤1.52 okanye i-radial lunate angle engaphezulu kwe-15°. I-MRI okanye i-CT inokunceda ekuchongeni ukungalungi kwethambo le-navicular okanye i-osteonecrosis. Ii-radiographs ezisecaleni okanye i-CT ye-oblique sagittal yethambo le-navicular ene-navicular angle >45° ibonisa ukufinyezwa kwethambo le-navicular, eyaziwa ngokuba yi-"bowed back deformity". I-MRI T1, i-T2 low signal ibonisa i-necrosis yethambo le-navicular, kodwa i-MRI ayinantsingiselo icacileyo ekumiseleni ukuphiliswa kokwaphuka.
Iimpawu kunye nokuchasana:
I-osteochondral nonunion ye-navicular enokukhubazeka komqolo ogobileyo kunye ne-DISI; I-MRI ibonisa i-ischemic necrosis yethambo le-navicular, ukukhululeka kwe-tourniquet ngaphakathi kotyando kunye nokujongwa kokuqhekeka kwesiphelo esiphukileyo sethambo le-navicular liseyithambo elimhlophe le-sclerotic; ukungaphumeleli kokufakelwa kwethambo lokuqala okanye ukulungiswa kwangaphakathi kwe-screw kufuna i-VGB enkulu yolwakhiwo lwethambo (> 1cm3). Iziphumo zangaphambi kotyando okanye zangaphakathi kwe-osteoarthritis yejoyinti ye-radial carpal; ukuba kuye kwenzeka i-navicular malunion ebalulekileyo ene-osteoarthritis ewayo, ngoko ke i-wrist denervation, i-navicular osteotomy, i-quadrangular fusion, i-proximal carpal osteotomy, i-total carpal fusion, njl.njl., inokufuneka; i-navicular malunion, i-proximal necrosis, kodwa nge-morphology yethambo le-navicular eqhelekileyo (umz., ukuqhekeka kwe-navicular okungasuswanga kunye nokunikezelwa kwegazi okungalunganga kwi-proximal pole); ukufinyezwa kwe-navicular malunion ngaphandle kwe-osteonecrosis. (I-1,2-ICSRA ingasetyenziswa endaweni ye-distal radius flap).
I-Anatomy esetyenzisiweyo
I-MFC VBG ibonelelwa ziimithambo ezincinci ze-trophoblastic ezidityanisiweyo (umyinge wama-30, 20-50), apho unikezelo lwegazi oluninzi lungaphantsi ngasemva kune-medial femoral condyle (umyinge wama-6.4), kulandele i-anteriorly superior (umyinge wama-4.9) (Umzobo 2). Ezi vessels ze-trophoblastic zibonelelwa ikakhulu yi-descending geniculate artery (DGA) kunye/okanye i-superior medial geniculate artery (SMGA), elilisebe le-superficial femoral artery elikwavelisa amasebe e-articular, musculocutaneous, kunye/okanye saphenous nerve. I-DGA ivela kwi-superficial femoral artery ekufutshane ne-medial eminence ye-medial malleolus, okanye kumgama we-13.7 cm ekufutshane nomphezulu we-articular (10.5-17.5 cm), kwaye ukuzinza kwe-branching kwakuyi-89% kwiisampuli zesidumbu (Umfanekiso 3). I-DGA ivela kumthambo we-femoral ongaphezulu kwi-13.7 cm (10.5 cm-17.5 cm) okufutshane nomngxuma we-medial malleolus okanye okufutshane nomphezulu we-articular, kunye nesampuli yesidumbu esibonisa uzinzo lwe-branching oluyi-100% kunye nobubanzi obumalunga ne-0.78 mm. Ke ngoko, nokuba yi-DGA okanye i-SMGA iyamkeleka, nangona eyangaphambili ifanelekile ngakumbi kwi-tibiae ngenxa yobude kunye nobubanzi bomkhumbi.
Umzobo 2. Ukusasazwa kwee-quadrant ezine zemithambo ye-MFC trophoblast kumgca othe tye phakathi kwe-semitendinosus kunye ne-medial collateral ligament A, umgca we-greater trochanter B, umgca we-superior pole ye-patella C, umgca we-anterior meniscus D.
Umfanekiso 3. I-anatomy yemithambo yegazi ye-MFC: (A) Amasebe angaqhelekanga kunye ne-anatomy yemithambo yegazi ye-MFC trophoblastic, (B) Umgama wemvelaphi yemithambo yegazi ukusuka kumgca odibeneyo
Ukufikelela ngotyando
Isigulana sibekwe phantsi kwe-anesthesia jikelele kwindawo yokulala phantsi, umlenze ochaphazelekayo ubekwe etafileni yotyando lwesandla. Ngokuqhelekileyo, i-donor bone flap ithathwa kwi-ipsilateral medial femoral condyle, ukuze isigulana sikwazi ukuhamba ngeentonga emva kotyando. Idolo elingasemva linokukhethwa ukuba kukho imbali yokwenzakala kwangaphambili okanye utyando kwicala elinye ledolo. Idolo liyagoba kwaye isinqe sijikeleziswa ngaphandle, kwaye ii-tourniquets zisetyenziswa kuzo zombini iindawo eziphezulu nezisezantsi. Indlela yotyando yayiyi-extended Russe approach, apho i-incision iqala nge-8 cm proximal ukuya kwi-transverse carpal tunnel kwaye isuka kude ukusuka kumda we-radial we-radial flexor carpi radialis tendon, ize igoqwe kwi-transverse carpal tunnel ukuya kwisiseko sesithupha, iphele kwinqanaba le-greater trochanter. I-tendon sheath ye-radial longissimus tendon iyanqunyulwa kwaye i-tendon itsalwa ulnar, kwaye ithambo le-navicular livezwa ngokuqhekeka okubukhali ecaleni kwe-radial lunate kunye ne-radial navicular head ligaments, ngokwahlula ngononophelo izicubu ezithambileyo zethambo le-navicular ukuvumela ukuvezwa okungakumbi kwethambo le-navicular (Umfanekiso 4). Qinisekisa indawo yokungahambelani, umgangatho we-articular cartilage kunye nobungakanani be-ischaemia yethambo le-navicular. Emva kokukhulula i-tourniquet, jonga i-proximal pole yethambo le-navicular ukuze ufumane ukopha kwegazi ukuze ubone ukuba kukho i-ischaemic necrosis. Ukuba i-navicular necrosis ayinxulunyaniswa ne-radial carpal okanye i-intercarpal arthritis, i-MFC VGB ingasetyenziswa.
Umfanekiso 4. Indlela yotyando lwe-navicular: (A) Ukusika kuqala nge-8 cm kufutshane ne-transverse carpal tunnel kwaye kwandisa umda we-radial we-radial flexor carpi radialis tendon ukuya kwinxalenye ekude ye-incision, egotywayo ukuya kwisiseko sesithupha kwi-transverse carpal tunnel. (B) I-tendon sheath ye-radial longissimus tendon iyanqunyulwa kwaye i-tendon itsalwa ulnarly, kwaye ithambo le-navicular livezwa ngokuqhekeka okubukhali ecaleni kwe-radial lunate kunye ne-radial navicular head ligaments. (C) Chonga indawo ye-navicular osseous discontinuity.
Kwenziwa ukusika okude okungange-15-20 cm kufutshane nomgca wedolo ecaleni komda ongasemva wemisipha ye-medial femoral, kwaye umsipha ubuyiselwa ngasemva ukuze kubonakale ukuhanjiswa kwegazi kwi-MFC (Umzobo 5). Ukunikezelwa kwegazi kwi-MFC ngokubanzi kunikezelwa ngamasebe adibeneyo e-DGA kunye ne-SMGA, ngokuqhelekileyo kuthatha isebe elikhulu le-DGA kunye nomthambo ohambelanayo. I-vascular pedicle ikhululwa kufutshane, ikhathalela ukukhusela i-periosteum kunye nemithambo ye-trophoblastic kumphezulu wamathambo.
Umfanekiso 5. Ukufikelela kwi-MFC ngotyando: (A) Kwenziwa isikere esibude buyi-15-20 cm ecaleni komda ongasemva wemisipha ye-medial femoral ukusuka kumgca wedolo. (B) Imisipha ibuyiselwa umva ngaphambili ukuze kubonakale ukuhanjiswa kwegazi kwi-MFC.
Ukulungiswa kwethambo le-navicular
Ukukhubazeka kwe-navicular DISI kufuneka kulungiswe kwaye indawo ye-osteochondral bone graft ilungiswe ngaphambi kokuba ifakwe ngokugoba isandla phantsi kwe-fluoroscopy ukubuyisela i-radial lunate angle eqhelekileyo (Umfanekiso 6). Iphini yeKirschner eyi-0.0625-foot (malunga ne-1.5-mm) ibholwa ngecala ukusuka kwi-dorsal ukuya kwi-metacarpal ukuze kulungiswe i-radial lunate joint, kwaye i-navicular malunion gap iyabonakala xa isandla silungisiwe. Indawo yokuqhekeka isusiwe izicubu ezithambileyo kwaye ivulwe ngakumbi nge-plate spreader. Isarha encinci ejikelezayo isetyenziselwa ukuthambisa ithambo kwaye iqinisekise ukuba i-implant flap ifana kakhulu nesakhiwo esingxande kune-wedge, efuna ukuba i-navicular gap iphathwe nge-gap ebanzi kwicala lesundu kunakwicala le-dorsal. Emva kokuvula i-gap, isiphene silinganiswa ngamanani amathathu ukuze kuchongwe ubungakanani be-bone graft, edla ngokuba yi-10-12 mm ubude kuwo onke amacala e-graft.
Umfanekiso 6. Ukulungiswa kokukhubazeka komqolo ogobileyo we-navicular, ngokujika kwesandla nge-fluoroscopic ukubuyisela ukulungelelaniswa okuqhelekileyo kwe-radial-lunar. Iphini yeKirschner eyi-0.0625-foot (malunga ne-1.5-mm) ibholwa ngecala ukusuka kwi-dorsal ukuya kwi-metacarpal ukuze kulungiswe i-radial lunate joint, iveze i-navicular malunion gap kwaye ibuyisele ukuphakama okuqhelekileyo kwethambo le-navicular xa isandla silungisiwe, kunye nobukhulu be-gap buxela ubungakanani be-flap esiya kufuneka ithintelwe.
I-Osteotomy
Indawo enemithambo yegazi ye-medial femoral condyle ikhethwa njengendawo yokukhupha amathambo, kwaye indawo yokukhupha amathambo iphawulwe ngokwaneleyo. Lumka ungalimazi i-medial collateral ligament. I-periosteum iyasikwa, kwaye i-rectangular bone flap enobukhulu obufanelekileyo be-flap oyifunayo iyasikwa ngesarha ejikelezayo, kunye ne-bone block yesibini esikiweyo kwi-45° kwelinye icala ukuqinisekisa ukuthembeka kwe-flap (Umzobo 7). 7). Kufuneka kuthathwe ingqalelo ukuba ungawahluli i-periosteum, i-cortical bone, kunye ne-cancellous bone ye-flap. I-tourniquet esezantsi kufuneka ikhululwe ukuze kubonwe ukuhamba kwegazi kwi-flap, kwaye i-vascular pedicle kufuneka ikhululwe kufutshane ubuncinane i-6 cm ukuvumela i-vascular anastomosis elandelayo. Ukuba kuyimfuneko, inani elincinci le-cancellous bone linokuqhubeka ngaphakathi kwe-femoral condyle. I-femoral condylar defect izaliswa nge-bone graft substitute, kwaye i-incision iyakhutshwa kwaye ivalwe ngomaleko ngomaleko.
Umfanekiso 7. Ukususwa kwe-MFC bone flap. (A) Indawo ye-osteotomy eyaneleyo ukuzalisa indawo ye-navicular iphawulwe, i-periosteum iyanqunyulwa, kwaye i-rectangular bone flap enobukhulu obufanelekileyo be-flap oyifunayo iyanqunyulwa ngesarha ejikelezayo. (B) Inxalenye yesibini yethambo iyanqunyulwa kwicala elinye kwi-45° ukuqinisekisa ukuthembeka kwe-flap.
Ukufakelwa kweflap kunye nokulungiswa kwayo
I-bone flap inqunyulwa ukuze ifane nemo efanelekileyo, kujongwa ukuba ayicinezeli i-vascular pedicle okanye isuse i-periosteum. I-flap ifakwa kancinci kwindawo ye-navicular bone defect, kuthintelwe ukubetheka, kwaye iqiniswe ngezikrufu ze-navicular ezingenanto. Kuye kwathathwa ingqwalasela ukuqinisekisa ukuba umda wesundu we-bone block efakelweyo uhlanjululwe ngomda wesundu wethambo le-navicular okanye ukuba ucinezelwe kancinci ukuze kuthintelwe ukuxinana. Kwenziwe i-fluoroscopy ukuqinisekisa imo yethambo le-navicular, umgca wamandla kunye nendawo ye-screw. Hlukanisa umthambo we-vascular flap ukuya kwicala le-radial artery kunye ne-venous tip ukuya kwicala le-radial artery companion vein (Umfanekiso 8). I-joint capsule iyalungiswa, kodwa i-vascular pedicle iyathintelwa.
Umfanekiso 8. Ukufakelwa kwethambo, ukulungiswa, kunye ne-vascular anastomosis. Ithambo lifakwa kancinci kwindawo ye-navicular bone defect kwaye lifakwe ngezikrufu ze-navicular ezingenanto okanye iiphini zeKirschner. Kucetyiswa ukuba umda we-metacarpal we-bone block efakelweyo uhlanjululwe ngomda we-metacarpal wethambo le-navicular okanye ucinezelwe kancinci ukuze kuthintelwe ukuxinana. I-Anastomosis ye-vascular flap artery kwi-radial artery yenziwe ukusuka ekuqaleni ukuya ekupheleni, kwaye incam ye-vein kwi-radial artery companion vein yenziwe ukusuka ekuqaleni ukuya ekupheleni.
Ukuvuselelwa emva kotyando
I-aspirin ethathwa ngomlomo engama-325 mg ngosuku (inyanga e-1), ukuthwala ubunzima bomlenze ochaphazelekayo emva kotyando kuyavunyelwa, ukuqhoboshelwa kwedolo kunokunciphisa ukungakhululeki komguli, kuxhomekeke ekubeni umguli uyakwazi na ukuhamba ngexesha elifanelekileyo. Inkxaso ye-contralateral ye-crutch enye inokunciphisa iintlungu, kodwa inkxaso yexesha elide yee-crutches ayifuneki. Izititshi zisusiwe kwiiveki ezi-2 emva kotyando kwaye i-Muenster okanye i-long arm to thumb cast igcinwe endaweni yayo iiveki ezi-3. Emva koko, i-short arm to thumb cast isetyenziswa de i-fracture iphole. Ii-X-ray zithathwa emva kweeveki ezi-3-6, kwaye ukuphiliswa kwe-fracture kuqinisekiswa yi-CT. Emva koko, imisebenzi esebenzayo neyokwenziwa ngaphandle kunye neyokwandiswa kufuneka iqalwe kancinci kancinci, kwaye ukuqina kunye nokuphindaphinda komthambo kufuneka kwandiswe kancinci kancinci.
Iingxaki ezinkulu
Iingxaki eziphambili zedolo ziquka intlungu yedolo okanye ukwenzakala kwemithambo-luvo. Iintlungu zedolo zenzeka kakhulu kwiiveki ezi-6 emva kotyando, kwaye akukho kulahleka kweemvakalelo okanye i-neuroma ebuhlungu ngenxa yokwenzakala kwemithambo-luvo engabonakaliyo. Iingxaki eziphambili zesandla zaziquka ukungahambelani kwamathambo anganyangekiyo, iintlungu, ukuqina kwamalungu, ubuthathaka, i-osteoarthritis eqhubekayo yesandla se-radial okanye amathambo e-intercarpal, kunye nomngcipheko we-periosteal heterotopic ossification nawo uxeliwe.
I-Medial Femoral Condyle Vascularised Bone Grafting yasimahla ye-Scaphoid Nonunions ene-Proximal Pole Avascular Necrosis kunye ne-Carpal Collapse
Ixesha leposi: Meyi-28-2024
