Indlela ye-suprapatellar yindlela yokuhlinzwa yokuguqulwa kwe-tibial intramedullary nail kwi-semi-extended knee position. Kukho iingenelo ezininzi, kodwa kunye nokungalunganga, ukwenza isikhonkwane se-intramedullary ye-tibia ngendlela ye-suprapatellar kwi-hallux valgus position. Abanye oogqirha bajwayele ukusebenzisa i-SPN ukunyanga zonke iifractures ze-tibial ngaphandle kwe-articular fractures ye-proximal 1/3 ye-tibia.
Iimpawu ze-SPN zezi:
1. Iifractures ezidibeneyo okanye zecandelo le-tibial stem. 2;
2. iifractures ze-distal tibial metaphysis;
3. ukuphulwa kwe-hip okanye idolo kunye nokukhawulelana kwangaphambili kwe-flexion (umzekelo, i-hip degenerative joint or fusion, i-osteoarthritis yamadolo) okanye ukungakwazi ukuguqula idolo okanye i-hip (umzekelo, ukuchithwa kwe-posterior ye-hip, ukuphulwa kwe-femur ipsilateral);
4. i-tibial fracture idibene nokulimala kwesikhumba kwi-tendon ye-infrapatellar;
5. i-tibial fracture kwisigulane esine-tibia ende kakhulu (isiphelo esiphezulu se-tibia sihlala sinzima ukubonwa phantsi kwe-fluoroscopy xa ubude be-tibia budlula ubude be-tripod apho i-fluoroscopy ingadlula khona).
Inzuzo ye-semi-extended knee position tibial intramedullary nail technique yonyango lwe-diaphysis ye-middle-tibial diaphysis kunye ne-distal tibial fractures ilele ekulula kokubuyisela kunye nokulula kwe-fluoroscopy. Le ndlela ivumela inkxaso egqwesileyo yobude obupheleleyo be-tibia kunye nokunciphisa i-sagittal elula yokuphuka ngaphandle kwesidingo sokukhwabanisa (Amanani 1, 2). Oku kuphelisa imfuno yomncedisi oqeqeshiweyo ukuncedisa ngobuchule be-intramedullary nail.
Umzobo 1: Isikhundla esiqhelekileyo sobuchule besikhonkwane se-intramedullary kwindlela ye-infrapatellar: idolo likwimeko eguquguqukayo kwi-tripod ene-fluoroscopically penetrable. Nangona kunjalo, esi sikhundla sinokwandisa ukulungelelaniswa okungahambi kakuhle kwebhloko ye-fracture kwaye ifuna iindlela ezongezelelweyo zokunciphisa ukunciphisa ukuphuka.
Umzobo we-2: Ngokwahlukileyo, indawo eyandisiweyo yamadolo kwi-ramp ye-foam iququzelela ukulungelelaniswa kwebhloko ye-fracture kunye nokuguqulwa okulandelayo.
IiTeknikhi zoTyando
Itheyibhile/Indawo Isigulana singqengqe kwindawo encopho phezu kwebhedi ene-fluoroscopic. Ukutsalwa kwe-Lower kungenziwa, kodwa akuyimfuneko.Itheyibhile yeVascular ifaneleka kakuhle kwi-suprapatellar approach tibial intramedullary nail, kodwa akuyimfuneko. Nangona kunjalo, iibhedi ezininzi zokubeka i-fracture okanye iibhedi ze-fluoroscopic azikhuthazwa njengoko zingafanelekanga kwi-suprapatellar approach tibial intramedullary nail.
Ukupakisha ithanga le-ipsilateral kunceda ukugcina umgca ophantsi kwindawo ejikelezayo yangaphandle. I-ramp ye-foam eyinyumba emva koko isetyenziselwa ukuphakamisa imilenze echaphazelekayo ngaphezu kwecala le-contralateral kwi-posterolateral fluoroscopy, kunye ne-flexible hip kunye nedolo isikhundla sikwanceda ekukhokeleni isikhonkwane kunye nokubekwa kwe-intramedullary nail. I-angle yokuguqa idolo elona lifanelekileyo kusaxoxwa ngayo, kunye noBeltran et al. iphakamisa i-10 ° ukuguqa kwedolo kunye ne-Kubiak ephakamisa i-30 ° ukuguqa kwamadolo. Uninzi lwabaphengululi luyavuma ukuba i-engile yokuguqa ngamadolo ngaphakathi kolu luhlu lwamkelekile.
Nangona kunjalo, u-Eastman et al. yafumanisa ukuba njengoko i-angle ye-knee flexion yanda ngokuthe ngcembe ukusuka kwi-10 ° ukuya kwi-50 °, umphumo we-femoral talon kwi-percutaneous penetration yesixhobo yancitshiswa. Ke ngoko, i-angle enkulu yokuguqula idolo iya kunceda ekukhetheni indawo echanekileyo yokungena kwi-intramedullary kunye nokulungisa ukukhubazeka kwe-angular kwindiza ye-sagittal.
I-Fluoroscopy
Umatshini we-C-arm kufuneka ubekwe kwicala elichasene netafile ukusuka kwilungu elichaphazelekayo, kwaye ukuba ugqirha umi kwicala ledolo elichaphazelekayo, i-monitor kufuneka ibe yintloko yomshini we-C-arm kwaye isondele. Oku kuvumela ugqirha kunye ne-radiologist ukuba baqaphele ngokulula imonitha, ngaphandle kokuba i-distal interlocking nail kufuneka ifakwe. Nangona kunganyanzelekanga, ababhali bacebisa ukuba i-C-arm ihanjiswe kwicala elinye kunye nogqirha wotyando kwelinye icala xa i-screw ye-medial interlocking iza kuqhutywa. Ngaphandle koko, umatshini we-C-arm kufuneka ubekwe kwicala elichaphazelekayo ngelixa ugqirha wenza inkqubo kwi-contralateral side (Umfanekiso 3). Le yindlela esetyenziswa ngokuqhelekileyo ngababhali kuba ithintela isidingo sokuba ugqirha wotyando atshintshe ukusuka kwicala eliphakathi ukuya kwicala elisecaleni xa uqhuba isikhonkwane sokutshixa i-distal.
Umzobo 3: Ugqirha umi kwicala elichasene ne-tibia echaphazelekayo ukwenzela ukuba i-screw interlocking ephakathi inokuqhutywa lula. Umboniso ubekwe ngokuchasene nogqirha wotyando, entloko ye-C-arm.
Zonke iimbono ze-anteroposterior kunye ne-medial-lateral fluoroscopic zifumaneka ngaphandle kokuhambisa ilungu elichaphazelekayo. Oku kunqanda ukufuduka kwendawo yokuqhekeka okuye kwaphinda kwamiselwa ngaphambi kokuba i-fracture ilungiswe ngokupheleleyo. Ukongezelela, imifanekiso yobude obupheleleyo be-tibia inokufumaneka ngaphandle kokunyathela i-C-arm ngendlela echazwe ngasentla.
Ukusikwa kolusu Zombini izikewu ezilinganiselweyo nezizandisiweyo zifanelekile. Indlela ye-percutaneous suprapatellar ye-intramedullary nail isekelwe ekusebenziseni i-3-cm incision yokuqhuba isikhonkwane. Uninzi lwezi zithintelo zotyando ziyi-longitudinal, kodwa ziyakwazi ukuguquguquka, njengoko kucetyiswa nguDkt Morandi, kunye ne-incision eyandisiweyo esetyenziswe nguDkt. Umzobo 4 ubonisa iindlela ezahlukeneyo zokusika.
Umzobo 4: Umzobo weendlela ezahlukeneyo zokuqhawula utyando.1- Suprapatellar transpatellar ligament approach; I-2- Parapatellar ligament approach; I-3- Indlela ye-Medial limited incision parapatellar ligament approach; I-4- I-Medial incision ligament parapatellar ligament approach; I-5- I-Lateral parapatellar ligament approach. I-exposure enzulu yendlela ye-parapatellar ligament ingaba yinto edibeneyo okanye ngaphandle kwe-joint bursa.
Ukubonakaliswa okunzulu
Indlela ye-percutaneous suprapatellar yenziwa ngokuyinhloko ngokuhlukanisa ixesha elide i-tendon ye-quadriceps de i-gap ikwazi ukufumana ukudlula kwezixhobo ezifana nezikhonkwane ze-intramedullary. I-parapatellar ligament approach, edlula ecaleni kwe-quadriceps muscle, ingaphinda iboniswe kwi-tibial intramedullary nail technique. Inaliti ye-trocar ene-blunt kunye ne-cannula idluliselwe ngokucophelela kwi-patellofemoral joint, inkqubo ekhokela ngokuyinhloko indawo yokungena yangaphambili ye-tibial intramedullary nail ngokusebenzisa i-trocar ye-femoral. Emva kokuba i-trocar ibekwe ngokuchanekileyo, kufuneka igcinwe kwindawo yokuphepha umonakalo kwi-articular cartilage yamadolo.
Indlela enkulu ye-transligamentous incision incision ingasetyenziswa ngokubambisana ne-hyperextension parapatellar skin incision, kunye nendlela ephakathi okanye esecaleni. Nangona abanye oogqirha botyando bengayigcini i-bursa ingasebenzi kakuhle, uKubiak et al. kholelwa ukuba i-bursa kufuneka igcinwe ingaguquki kwaye izakhiwo ezingaphezulu kufuneka zibonakaliswe ngokwaneleyo. Ngokwethiyori, oku kubonelela ngokhuseleko olubalaseleyo lwamadolo kunye nokuthintela umonakalo onjengosulelo lwedolo.
Indlela echazwe ngasentla iphinda ibandakanye i-hemi-dislocation ye-patella, eyanciphisa uxinzelelo loqhagamshelwano kwiindawo ze-articular kwinqanaba elithile. Xa kunzima ukwenza uvavanyo oludibeneyo lwe-patellofemoral kunye nesigxina esincinci esidibeneyo kunye nesixhobo esincinci sokwandisa idolo, ababhali bancoma ukuba i-patella inokuthi i-semi-dislocated ngokuhlukana kwe-ligament. I-median transverse incision, ngakolunye uhlangothi, igwema umonakalo kwi-ligaments exhasayo, kodwa kunzima ukwenza ukulungiswa kokulimala kwamadolo.
Indawo yokungena inaliti ye-SPN iyafana nendlela ye-infrapatellar. I-fluoroscopy yangaphambili kunye necala ngexesha lokufakwa kwenaliti iqinisekisa ukuba indawo yokufaka inaliti ichanekile. Ugqirha wotyando kufuneka aqinisekise ukuba inaliti ekhokelayo ayiqhutyelwa kude kakhulu ngasemva kwi-tibia esondeleyo. Ukuba iqhutywe kakhulu ngasemva, kufuneka ihlaziywe ngoncedo lwesikhonkwane sokuthintela phantsi kwe-coronal fluoroscopy yangasemva. Ukongeza, u-Eastman et al. kholelwa ukuba ukubhobhoza iphini lokungena kwindawo echazwe edolophini eguquguqukayo inceda ekubuyiseleni i-fracture elandelayo kwi-hyperextended position.
Izixhobo zokunciphisa
Izixhobo ezisebenzayo zokunciphisa ziquka i-forceps yokunciphisa amanqaku ubukhulu obuhlukeneyo, abaphakamisi be-femoral, izixhobo zokulungisa zangaphandle, kunye nezilungisi zangaphakathi zokulungiswa kwamaqhekeza amancinci aqhekezayo kunye nepleyiti enye ye-cortical. Izikhonkwane zokuthintela zingasetyenziselwa le nkqubo yokunciphisa ikhankanywe ngasentla. Iihamile zokunciphisa zisetyenziselwa ukulungisa i-sagittal angulation kunye ne-transverse displacement deformities.
Ukufakelwa
Abavelisi abaninzi be-orthopedic fixators yangaphakathi baye baphuhlisa iinkqubo zokusetyenziswa kwezixhobo zokukhokela ukubekwa okusemgangathweni kwezikhonkwane ze-tibial intramedullary. Ibandakanya ingalo yokumisa eyandisiweyo, isixhobo sokulinganisa ubude bephini elikhokelwayo, kunye nesandisi se-medullary. Kubaluleke kakhulu ukuba i-trocar kunye ne-blunt trocar pins ikhusele ukufikelela kwi-intramedullary nail kakuhle. Ugqirha kufuneka aqinisekise kwakhona indawo ye-cannula ukwenzela ukuba ukulimala kwi-patellofemoral joint okanye izakhiwo ze-periarticular ngenxa yokusondela kakhulu kwisixhobo sokuqhuba akwenzeki.
Izikrufu zokutshixa
Ugqirha wotyando kufuneka aqinisekise ukuba kufakwe inani elaneleyo lezikrufu zokutshixa ukuze kugcinwe ukuncipha okwanelisayo. Ukulungiswa kwamaqhekeza amancinci amancinci (i-proximal okanye i-distal) ifezekiswa nge-screws ezi-3 okanye ngaphezulu zokutshixa phakathi kweeqhekeza ezikufutshane eziqhekezayo, okanye ngezikrufu ezisisigxina zodwa. Indlela ye-suprapatellar kwi-tibial intramedullary nail technique ifana nendlela ye-infrapatellar malunga ne-screw driving technique. Izikrufu zokutshixa ziqhutywa ngokuchanekileyo ngakumbi phantsi kwe-fluoroscopy.
Ukuvalwa kwenxeba
Ukufunxa ngecasing yangaphandle efanelekileyo ngexesha lokwandiswa kususa amaqhekeza amathambo asimahla. Zonke izilonda kufuneka zinkcenkceshelwe ngokucokisekileyo, ngakumbi indawo yokuhlinzwa edolweni. I-tendon ye-quadriceps okanye i-ligament layer kunye ne-suture kwindawo yokukrazula emva koko ivalwe, ilandelwa ukuvala i-dermis kunye nesikhumba.
Ukususwa kwesikhonkwane se-intramedullary
Ingaba i-tibial intramedullary nail eqhutywe ngendlela ye-suprapatellar ingasuswa ngendlela eyahlukileyo yokuhlinzwa ihlala iphikisana. Eyona ndlela iqhelekileyo yindlela ye-transarticular suprapatellar yokususwa kwe-intramedullary nail. Obu buchule buveza isikhonkwane ngokubhoboza umjelo wesikhonkwane we-suprapatellar intramedullary usebenzisa i-drill ehollow eyi-5.5 mm. Isixhobo sokususa isikhonkwane siqhutywa kwitshaneli, kodwa le ndlela yokuhambisa inokuba nzima. Iindlela ze-parapatellar kunye ne-infrapatellar zezinye iindlela zokususa izikhonkwane ze-intramedullary.
Imingcipheko Iingozi zotyando lwendlela ye-suprapatellar kwi-tibial intramedullary nail technique yingozi yonyango kwi-patella kunye ne-femoral talus cartilage, ukulimala kwezonyango kwezinye izakhiwo ze-intra-articular, ukusuleleka ngokubambisana, kunye ne-intra-articular debris. Nangona kunjalo, kukho ukungabikho kweengxelo zeklinikhi ezihambelanayo. Izigulane ezine-chondromalacia ziya kuba zilungele ngakumbi ukulimala kwe-cartilage eyenziwa ngonyango. Umonakalo wezonyango kwi-patellar kunye ne-femoral articular surface structures yinkxalabo enkulu yoogqirha abasebenzisa le ndlela yotyando, ngakumbi indlela ye-transarticular.
Ukuza kuthi ga ngoku, akukho bungqina beklinikhi bamanani malunga neenzuzo kunye nokungonakali kwe-semi-extension tibial intramedullary nail technique.
Ixesha lokuposa: Oct-23-2023
