Indlela ye-suprapatellar yindlela yotyando ehlengahlengisiweyo ye-tibial intramedullary nail kwindawo yedolo elolulwe kancinci. Zininzi iingenelo, kodwa zikwakho neengxaki, zokwenza uzipho lwe-intramedullary lwe-tibia ngendlela ye-suprapatellar kwindawo ye-hallux valgus. Abanye oogqirha baqhele ukusebenzisa i-SPN ukunyanga zonke izaphuko ze-tibial ngaphandle kwezaphuko ze-extra-articular ze-proximal 1/3 ye-tibia.
Iimpawu ze-SPN zezi:
1. Ukuqhekeka kwesiqu se-tibial okuqhekekileyo okanye okuqhekekileyo. 2;
2. ukwaphuka kwe-distal tibial metaphysis;
3. ukwaphuka kwesinqe okanye idolo kunye nokunciphisa ukujijeka kwangaphambili (umz., i-degenerative hip joint okanye i-fusion, i-osteoarthritis yedolo) okanye ukungakwazi ukujijeka kwedolo okanye isinqe (umz., ukudilika kwesinqe ngasemva, ukwaphuka kwe-ipsilateral femur);
4. ukwaphuka kwe-tibial kunye nokwenzakala kwesikhumba kwi-tendon ye-infrapatellar;
5. ukwaphuka kwe-tibial kwisigulana esine-tibia ende kakhulu (isiphelo esikufutshane se-tibia sidla ngokuba nzima ukusibona phantsi kwe-fluoroscopy xa ubude be-tibia budlula ubude be-tripod apho i-fluoroscopy inokudlula khona).
Inzuzo yendlela yokwenza izipikili ze-intramedullary zedolo ezikwi-semi-extended knee position kunyango lwe-mid-tibial diaphysis kunye ne-distal tibial fractures ikukulula kokubeka kwakhona kunye nokulula kwe-fluoroscopy. Le ndlela ivumela inkxaso egqwesileyo yobude obupheleleyo be-tibia kunye nokunciphisa ngokulula i-sagittal yokwaphuka ngaphandle kwesidingo sokuyilawula (Imifanekiso 1, 2). Oku kususa imfuneko yomncedisi oqeqeshiweyo wokuncedisa nge-intramedullary nail technique.
Umfanekiso 1: Indawo eqhelekileyo yendlela yokwenza iinzipho ngaphakathi kwe-medullary kwindlela ye-infrapatellar: idolo likwindawo egobileyo kwi-tripod engenekayo ene-fluoroscopically. Nangona kunjalo, le ndawo ingenza kube nzima ukulungelelanisa ibhloko yokuqhekeka kwaye ifuna iindlela ezongezelelweyo zokunciphisa ukuqhekeka.
Umfanekiso 2: Ngokwahlukileyo koko, indawo ende yedolo kwi-foam ramp yenza kube lula ukulungelelaniswa kweebhloko zokuqhekeka kunye nokuguqulwa okulandelayo.
Iindlela Zotyando
Itafile/Indawo Isigulana silele phantsi kwibhedi ye-fluoroscopic. Kunokwenziwa ukutsala umlenze ongezantsi, kodwa akufuneki. Itafile yeVascular ifanelekile kwi-suprapatellar approach tibial intramedullary nail, kodwa ayifuneki. Nangona kunjalo, uninzi lweebhedi zokubeka ukwaphuka okanye iibhedi ze-fluoroscopic azikhuthazwa kuba azifanelekanga kwi-suprapatellar approach tibial intramedullary nail.
Ukufaka ithanga elisecaleni kunceda ukugcina umphetho ongezantsi ujikelezwe ngaphandle. I-ramp ye-foam ecocekileyo isetyenziselwa ukuphakamisa ilungu elichaphazelekayo ngaphezulu kwecala elisecaleni ukuze kwenziwe i-posterolateral fluoroscopy, kwaye indawo ye-hip kunye nedolo egobileyo ikwanceda ekuqondiseni indawo ye-pin kunye ne-intramedullary. I-angle efanelekileyo yokugoba idolo isaxoxwa, apho uBeltran et al. ecebisa ukugoba idolo nge-10° kwaye uKubiak ecebisa ukugoba idolo nge-30°. Uninzi lweengcali ziyavuma ukuba ii-engile zokugoba idolo ngaphakathi kwezi zigaba ziyamkeleka.
Nangona kunjalo, u-Eastman nabanye bafumanise ukuba njengoko i-engile yokujika kwamadolo yayinyuka kancinci ukusuka kwi-10° ukuya kwi-50°, isiphumo se-femoral talon ekungeneni kwesixhobo nge-percutaneous sancitshiswa. Ke ngoko, i-engile enkulu yokujika kwamadolo iya kunceda ekukhetheni indawo efanelekileyo yokungena kwezipikili ngaphakathi kwe-medullary kunye nokulungisa ukukhubazeka kwe-angular kwi-sagittal plane.
I-Fluoroscopy
Umatshini we-C-arm kufuneka ubekwe kwelinye icala letafile ukusuka kwilungu elichaphazelekayo, kwaye ukuba ugqirha umi ecaleni kwedolo elichaphazelekayo, isikrini kufuneka sibe sentloko yomatshini we-C-arm kwaye sibe kufutshane. Oku kuvumela ugqirha kunye nengcali ye-radiology ukuba babone ngokulula isikrini, ngaphandle kokuba kufuneka kufakwe isikhonkwane esidibanisayo kude. Nangona kungengomfuneko, ababhali bacebisa ukuba ingalo ye-C ihanjiswe kwelinye icala kwaye ugqirha ahanjiswe kwelinye icala xa kufuneka kuqhutywe isikrufu esidibanisayo se-medial. Ngaphandle koko, umatshini we-C-arm kufuneka ubekwe kwelinye icala elichaphazelekayo ngelixa ugqirha esenza inkqubo kwicala elichaseneyo (Umfanekiso 3). Le yindlela esetyenziswa kakhulu ngababhali kuba ithintela isidingo sokuba ugqirha atshintshe ukusuka kwicala eliphakathi aye kwelinye icala xa eqhuba isikhonkwane esidibanisayo kude.
Umfanekiso 3: Ugqirha umi kwicala elichaseneyo le-tibia echaphazelekayo ukuze isikrufu esidibanisayo esiphakathi sikwazi ukuqhutywa lula. Isiboniso sibekwe ecaleni kogqirha, entloko yengalo ye-C.
Zonke iimbono ze-fluoroscopic ze-anteroposterior kunye ne-medial-lateral zifunyanwa ngaphandle kokuhambisa ilungu elichaphazelekayo. Oku kuthintela ukufuduka kwendawo yokuqhekeka esele ilungisiwe ngaphambi kokuba ukwaphuka kulungiswe ngokupheleleyo. Ukongeza, imifanekiso yobude obupheleleyo be-tibia ingafunyanwa ngaphandle kokuthambekisa ingalo ye-C ngendlela echazwe apha ngasentla.
Ukusikwa kwesikhumba Zombini izisikwa ezilinganiselweyo nezinde ngokufanelekileyo zifanelekile. Indlela ye-percutaneous suprapatellar ye-intramedullary nail isekelwe ekusebenziseni isisikwa esiyi-3-cm ukuqhuba uzipho. Uninzi lwale misikwa yotyando luhlala ixesha elide, kodwa lunokuba lujikelezileyo, njengoko kucetyisiwe nguGqr. Morandi, kwaye isisikwa esongezelelweyo esisetyenziswe nguGqr. Tornetta nabanye siboniswa kwizigulana ezine-combined patellar subluxation, ezine-medial okanye lateral parapatellar approach. Umfanekiso 4 ubonisa izisikwa ezahlukeneyo.
Umfanekiso 4: Umfanekiso weendlela ezahlukeneyo zokusikwa ngotyando.1- Indlela ye-Suprapatellar transpatellar ligament; 2- Indlela ye-Parapatellar ligament; 3- Indlela ye-Medial limited incision parapatellar ligament; 4- Indlela ye-Medial ended incision parapatellar ligament; 5- Indlela ye-lateral parapatellar ligament. Ukuvezwa okunzulu kwendlela ye-parapatellar ligament kunokuba nge-joint okanye ngaphandle kwe-joint bursa.
Ukuvezwa nzulu
Indlela ye-percutaneous suprapatellar yenziwa ngokuyintloko ngokwahlula i-tendon ye-quadriceps ngobude de kube yilapho umsantsa ukwazi ukwamkela ukuhamba kwezixhobo ezifana nezipikili ze-intramedullary. Indlela ye-parapatellar ligament, edlula ecaleni kwemisipha ye-quadriceps, inokuboniswa nakwindlela ye-tibial intramedullary nail. Inaliti ye-trocar e-blunt kunye ne-cannula zidluliselwa ngononophelo kwi-patellofemoral joint, inkqubo ekhokela ngokuyintloko indawo yokungena ye-anterior-superior ye-tibial intramedullary nail ngokusebenzisa i-femoral trocar. Nje ukuba i-trocar ibekwe ngokuchanekileyo, kufuneka iqiniswe endaweni yayo ukuze kuthintelwe ukonakala kwe-articular cartilage yedolo.
Indlela enkulu yokusikwa kwe-transligamentous ingasetyenziswa kunye ne-hyperextension parapatellar skin incision, nokuba yindlela ye-medial okanye ye-lateral. Nangona abanye oogqirha bengayigcini i-bursa iphelele ngexesha lotyando, uKubiak nabanye bakholelwa ukuba i-bursa kufuneka igcinwe iphelele kwaye izakhiwo ezingaphandle kwe-articular kufuneka zibonakale ngokwaneleyo. Ngokwethiyori, oku kubonelela ngokhuseleko oluhle kakhulu kwilungu ledolo kwaye kuthintela umonakalo onjengosulelo lwedolo.
Le ndlela ichazwe apha ngasentla ikwabandakanya ukudilika kwe-patella, okunciphisa uxinzelelo lokudibana kwiindawo ezidityanisiweyo ukuya kuthi ga kwinqanaba elithile. Xa kunzima ukwenza uvavanyo lwamalungu e-patellofemoral nge-joint cavity encinci kunye nesixhobo sokwandisa idolo esincinci kakhulu, ababhali bacebisa ukuba i-patella ingadilika kancinci ngokuhlukana kwe-ligament. Kwelinye icala, i-median transverse incision ithintela ukonakala kwe-ligaments ezixhasayo, kodwa kunzima ukwenza ukulungiswa kokulimala kwedolo ngempumelelo.
Indawo yokungena kwenaliti ye-SPN iyafana naleyo yendlela ye-infrapatellar. I-fluoroscopy yangaphambili neyasecaleni ngexesha lokufakwa kwenaliti iqinisekisa ukuba indawo yokufakwa kwenaliti ichanekile. Ugqirha kufuneka aqinisekise ukuba inaliti ekhokelayo ayitsalwa kakhulu ngasemva iye kwi-proximal tibia. Ukuba itsalwa nzulu kakhulu ngasemva, kufuneka ibekwe kwakhona ngoncedo lwesikhonkwane esivimbayo phantsi kwe-posterior coronal fluoroscopy. Ukongeza, u-Eastman nabanye bakholelwa ukuba ukubhoboza iphini yokungena kwindawo egudileyo ecacileyo kunceda ekutshintsheni ukwaphuka okulandelayo kwindawo ende.
Izixhobo zokunciphisa
Izixhobo ezisebenzayo zokunciphisa ziquka ii-forceps zokunciphisa amanqaku ezinobukhulu obahlukeneyo, ii-femoral lifters, izixhobo zokulungisa zangaphandle, kunye nee-fixators zangaphakathi zokulungisa iziqwenga ezincinci zokuqhekeka nge-cortical plate enye. Izikhonkwane ezivimbayo zingasetyenziselwa inkqubo yokunciphisa ekhankanyiweyo apha ngasentla. Ii-Reduction Hammers zisetyenziselwa ukulungisa i-sagittal angulation kunye ne-transverse displacement deformities.
Izimila
Abavelisi abaninzi bee-orthopedic internal fixators baphuhlise iinkqubo zokusetyenziswa kwezixhobo ukukhokela ukubekwa okuqhelekileyo kwezipikili ze-intramedullary ze-tibial. Ziquka ingalo ende yokuma, isixhobo sokulinganisa ubude bephini ekhokelwayo, kunye ne-medullary expander. Kubaluleke kakhulu ukuba iiphini ze-trocar kunye ne-blunt trocar zikhusele ukufikelela kakuhle kwezipikili ze-intramedullary. Ugqirha kufuneka aqinisekise kwakhona indawo ye-cannula ukuze kungenzeki ukwenzakala kwi-patellofemoral joint okanye kwizakhiwo ze-periarticular ngenxa yokusondela kakhulu kwisixhobo sokuqhuba.
Izikrufu zokutshixa
Ugqirha kufuneka aqinisekise ukuba kufakwa inani elaneleyo lezikrufu zokutshixa ukuze kugcinwe ukuncipha okwanelisayo. Ukulungiswa kweziqwenga ezincinci zokutshixa (ezikufutshane okanye ezikude) kwenziwa ngezikrufu zokutshixa ezi-3 okanye ngaphezulu phakathi kweziqwenga zokutshixa ezikufutshane, okanye ngezikrufu ezine-engile ezinzileyo zodwa. Indlela ye-suprapatellar kwindlela ye-tibial intramedullary nail ifana nendlela ye-infrapatellar ngokwendlela yokuqhuba izikrufu. Izikrufu zokutshixa ziqhutywa ngokuchanekileyo ngakumbi phantsi kwe-fluoroscopy.
Ukuvalwa kwenxeba
Ukufunxa ngesiciko sangaphandle esifanelekileyo ngexesha lokwandiswa kususa amaqhekeza amathambo akhululekileyo. Onke amanxeba kufuneka ankcenkceshelwe kakuhle, ingakumbi indawo yotyando lwedolo. I-tendon ye-quadriceps okanye umaleko we-ligament kunye nomthungo kwindawo yokuqhekeka ziyavalwa, kulandele ukuvalwa kwe-dermis kunye nolusu.
Ukususwa kweenzipho ze-intramedullary
Nokuba isikhonkwane se-tibial intramedullary esiqhutywa ngendlela ye-suprapatellar sinokususwa ngendlela eyahlukileyo yotyando kusaqhubeka kuyimpikiswano. Eyona ndlela ixhaphakileyo yindlela ye-transarticular suprapatellar yokususa izikhonkwane ze-intramedullary. Le ndlela ityhila isikhonkwane ngokugqobhoza kwitshaneli yezikhonkwane ze-suprapatellar intramedullary kusetyenziswa i-drill engenanto eyi-5.5 mm. Isixhobo sokususa izikhonkwane emva koko siqhutywa kwitshaneli, kodwa olu hambo lunokuba nzima. Iindlela ze-parapatellar kunye ne-infrapatellar ziindlela ezizezinye zokususa izikhonkwane ze-intramedullary.
Iingozi Iingozi zotyando lwendlela ye-suprapatellar kwindlela ye-tibial intramedullary nail technique kukwenzakala kwezonyango kwi-patella kunye ne-femoral talus cartilage, ukwenzakala kwezonyango kwezinye izakhiwo zangaphakathi kwe-articular, usulelo lwamalungu, kunye neenkunkuma zangaphakathi kwe-articular. Nangona kunjalo, akukho ngxelo yezonyango ehambelanayo. Izigulane ezine-chondromalacia ziya kuba sengozini enkulu yokwenzakala kwe-cartilage okubangelwa ngugqirha. Umonakalo wezonyango kwizakhiwo zomphezulu we-patellar kunye ne-femoral articular yinkxalabo enkulu koogqirha abasebenzisa le ndlela yotyando, ingakumbi indlela ye-transarticular.
Ukuza kuthi ga ngoku, akukho bungqina bezonyango obukhoyo malunga neenzuzo kunye nokungalungi kwendlela yokwenza iinzipho ze-semi-extension tibial intramedullary.
Ixesha lokuthumela: Okthobha-23-2023
