Tibial Intramedullary Nail Fixation Mɔnu

Intramedullary nail fixation gakpɔtɔ nye atike si wotia na tibial stem fractures si meli ke o eye woɖena le ame tsitsiwo me. Taɖodzinu si le amekoko ƒe atikewɔwɔ ŋue nye be woagbugbɔ afɔkpodzi ƒe didime, wòasɔ ɖe ɖoɖo nu kple eƒe tɔtrɔ aɖo anyi eye woakpɔ afɔkpodzi ƒe gbagbã ƒe dɔyɔyɔ gbɔ. Viɖe siwo le ɖaƒoƒo ɖe lãkusi me ŋue nye be amekoko ƒe nuveviwɔame suetɔ kekeake kple ʋu si yia aɖuɖɔtoea me ƒe takpɔkpɔ nyuie. Tsɔ kpe ɖe eŋu la, afɔkpodzi ƒe atitsotso le lãkusi me naa biomechanical fracture ƒe liƒo si sɔ eye wòwɔa dɔ abe agbamama ƒe mɔ̃ si ɖea mɔ be woate ŋu aʋuʋui kabakaba le dɔwɔwɔ vɔ megbe ene. Ŋgɔyiyi siwo wowɔ le ɖa si le lãkusi me ƒe wɔwɔme kple edzi ɖeɖe kpɔtɔ ƒe mɔnuwo me keke dzesi siwo woatsɔ alé ɖa ɖe lãkusi me ɖe enu ɖe ​​enu wòxɔ afɔkpodzi si te ɖe eŋu kple titina ƒe akpa etɔ̃lia ƒe gbagbã le ete.

Vaseɖe egbea la, closed reduction intramedullary nail fixation of tibial fractures va zu nusi bɔ na ƒumeŋutinunyala siwo wɔa nuvevi ame. Togbɔ be ame geɖe lɔ̃a ɖa si wotsɔna ƒoa ɖae le lãkusi me na afɔkpodzi ƒe ke ƒe gbagbã siwo woɖe ɖa hã la, egakpɔtɔ nye kuxi eye kuxi geɖe siwo ate ŋu ado mo ɖa. Amekokomɔnuwo yi edzi le tɔtrɔm. Taɖodzinu si le nyati sia ŋue nye be míaƒo nu tso nukpɔsusu siwo li fifia le ɖa si wotsɔna ƒoa ɖae le lãkusi me ƒe ʋuʋu le tibial stem fractures ŋu me eye míaƒo nu tso ŋgɔyiyi siwo wowɔ nyitsɔ laa le dɔa me ŋu kpuie.

一 ƒe nya. Gbãtɔ ƒe dodokpɔ kple ŋkuléle ɖe eŋu

Le dɔnɔ siwo metsi o gome la, zi geɖe la, abi siwo ŋu ŋusẽ geɖe le gbɔe afɔkpodzi ƒe ke ƒe gbagbã tsona, eye ele be woada dɔnɔwo kpɔ be nuveviwɔame si do ƒome kplii hã le Advanced Trauma Life Support (ATLS) ƒe mɔfiamewo nu. Da abi siwo ƒo xlã ŋutigbalẽ kple lãkusi falɛfalɛwo abe ŋutigbalẽ ƒe ʋuʋu, ŋutigbalẽ ƒe ʋuʋu, dzobibi, ecchymosis, alo ŋutigbalẽ ƒe kɔkɔme kpɔ; na eme nakɔ nenye be ʋu gbagbãa ʋu, eye ne ele nenema la, nàtsɔ tetanus kple dɔlékuiwutikewo adae; eye nàdo ahɔhɔ̃mekawo kpɔ nyuie eye nàŋlɔ nya siwo le etame la ɖi. Da ƒumeŋuɖui ƒe dɔléle ƒe dzɔdzɔ kpɔ eye nàwɔ dɔdamɔnu dodokpɔ vovovowo le dɔnɔ siawo ŋu.

Numekuku siwo wowɔ nyitsɔ laa ɖee fia be osteofascial compartment syndrome ƒe dzɔdzɔ le tibial tuberosity fractures megbe ate ŋu asɔ gbɔ abe 11.5 % ene. Vevietɔ dɔnɔwo ƒe ƒuƒoƒo siwo metsi o ate ŋu axɔ ƒumeŋuɖui ƒe dɔléle. Ele be woanɔ te ɖe nusiwo ŋu woke ɖo le atikewɔƒewo dzi anya ƒumeŋuɖui ƒe dɔléle, siwo dometɔ aɖewoe nye vevesese sesẽ, ahɔhɔ̃mekawo ƒe tɔtrɔ, lãkusi ƒe vuvu, kple vevesese si dzina ɖe edzi tso afɔbidɛ ƒe kekeɖenudɔwɔwɔ si mewɔa dɔ o gbɔ. Eyata ƒumeŋuɖui ƒe dɔléle gakpɔtɔ nye dɔléle si wokpɔna le dɔdaƒe eye dɔdaƒea ƒe dodokpɔa ŋuti nuŋlɔɖi tsitotsito le vevie ŋutɔ. Woate ŋu adzidze nyaƒoɖeamenu si le myofascial compartment me to pressure needle (Nɔnɔmetata 1) dzi abe dodokpɔmɔnu si kpe ɖe dodokpɔ tɔxɛa ŋu ene.

Figure 1. Nyaƒoɖeamenu dzidzedze le ƒuwo dome ʋuka me to nyaƒoɖeamenu ƒe aŋe dzi

Be woakpɔ nyatakaka siwo ŋu kakaɖedzi le la, ele be woadzidze lãkusi me nyaƒoɖeamenu le lãkusi ƒe akpa eneawo me kple le teƒe vovovowo le lãkusi ƒe akpa ɖesiaɖe me. Numekuku siwo wowɔ le agbalẽwo me ɖee fia be vovototo si le nyaƒoɖeamenu si mede 30 mmHg o (diastolic pressure minus fascial compartment pressure) fia be fascial compartment syndrome. Zi geɖe la, diastolic pressure dzi ɖena kpɔtɔna le amekoko me, eye ele be woabu diastolic pressure do ŋgɔ na dɔwɔwɔ nɛ ne wole akɔnta bum le vovototo ƒe nyaƒoɖeamenu ŋu.

Numekuku siwo wowɔ nyitsɔ laa ɖee fia be ŋkuléle ɖe lãkusi me ƒe nyaƒoɖeamenu ŋu nye dɔwɔnu si ate ŋu aɖe vi na dɔléle si nye acute fascial compartment syndrome, si ƒe seselelãme nye 94 % eye eƒe vovototo nye 98 %. Gake le nusiwo ate ŋu agblẽ nu le dɔnɔdzikpɔƒe ƒe dɔlélea ŋu ta la, ele be woanɔ te ɖe nusiwo ŋu woke ɖo le dɔdaƒewo dzi anya compartment syndrome, eye woazã ƒuwo dome ʋukawo ƒe nyaƒoɖeamenu dzidzedze le nɔnɔme tɔxɛwo me, abe ne dɔnɔa xɔ abi alo ne dɔdamɔnu ŋuti nyatakakawo me mekɔ o ene.

Ele be nɔnɔmetatawo ƒe dodokpɔ nanye orthopantomogram siwo wozãna ɖaa kple afɔkpodzi si xɔ abi ƒe axadzikpɔkpɔ kple klo kple afɔkpodzi ƒe ƒunukpeƒe siwo te ɖe wo nɔewo ŋu ƒe radiographs, siwo wogazãa computed tomography (CT) tsɔ daa wo kpɔna ɖe edzi. Nenema ke ate ŋu ahiã be woawɔ afɔkpodzi ƒe CT-dɔdamɔnu be woakpɔ fli siwo me gbagbã le siwo keke ta ɖo afɔkpodzi ƒe gbadzaƒe kple abi siwo mewɔ ɖeka kple afɔkpodzi o siwo do ƒome kplii la le susu me

二 ƒe nya. Dɔnɔdzikpɔƒe ƒe mɔ̃tetrewo

Woka nya ta be afɔkpodzi ƒe titina ƒe akpa etɔ̃lia si le anyime ƒe gbagbã kple afɔkpodzi ƒe gbagbã ƒe alafa memamã geɖe. Ne wozã CT-dɔdamɔnu siwo wozãna ɖaa la, afɔkpodzi ƒe titina kple ete ƒe akpa etɔ̃lia ƒe gbagbã 43 % kpe ɖe afɔkpodzi ƒe gbagbã ŋu, eye wo dometɔ akpa gãtɔ hiã amekoko. Afɔkpodzi ƒe gbagbã ƒomevi si bɔ wue nye afɔkpodzi ƒe akpa si le didiƒe ƒe titina ƒe akpa etɔ̃lia si le anyime ƒe gbagbã si do ƒome kple megbefɔti ƒe gbagbã vie alo si meʋuʋu o (Nɔnɔmetata 2). Le afɔkpodzi ƒe gbagbã si do ƒome kplii ƒe ʋuʋu sue ta la, abi siwo woxɔ ƒe 45 % koe woate ŋu akpɔ le afɔkpodzi ƒe fotoɖeɖe dzrowo me. Eyata ele be woate gbe ɖe afɔkpodzi ƒe CT-dɔdamɔnu si wowɔna edziedzi dzi vevie ne titina afɔkpodzi ƒe akpa si le ete ƒe gbagbã le afima (Nɔnɔm. 3).

Figure 2.AF Spiral fracture of the lower middle third of the right tibia (A, B) Afɔkpodzi ƒe fotoɖeɖe do ŋgɔ na dɔwɔwɔ nɛ ɖee fia be esɔ (C). Intraoperative C-arm fluoroscopy ɖea megbefɔti ƒe gbagbã si womeɖe le teƒe bubu o fiana (D) Dɔwɔwɔ vɔ megbe ƒe radiographs le amekoko ƒe fixation (EF) megbe ɖea tibial kple afɔkpodzi ƒe gbagbãwo ƒe dɔyɔyɔ nyuie fiana

Nɔnɔmetata 3. AF Miame ƒe afɔkpodzi ƒe titina kple eƒe akpa etɔ̃lia si le ete ƒe gbagbã le ʋuʋudedi me (AB) ƒe fotoɖeɖe do ŋgɔ na dɔwɔwɔ nɛ; (CD) CT-dɔdamɔnu siwo woɖe do ŋgɔ na dɔwɔwɔ nɛ siwo ɖee fia be megbeƒu ƒe gbagbã si womeʋu o; (EF) si ɖee fia be afɔkpodzi kple afɔkpodzi ƒe gbagbã ƒe dɔyɔyɔ nudzɔdzɔ aɖeke manɔmee

三 ƒe nya. Amekokomɔnu siwo wozãna

01. Tibial Needle ƒe Gegeɖeƒe

Afisi woage ɖo si sɔ ɖoɖo anyi wɔa akpa vevi aɖe eye numekuku geɖe siwo wowɔ le agbalẽwo me na nyatakaka veviwo le ŋutilã ƒe teƒe si teƒe nyuitɔ si woate ŋu age ɖo na afɔkpodzi ƒe gbagbãƒewo ƒe atitsoga le lãkusi me ŋu. Numekuku siawo ɖee fia be teƒe nyuitɔ si woatsɔ ablae le la le tibial plateau ƒe ŋgɔgbekpa dzi eye wòle titina tututu le tibial spur si le axadzi la gbɔ. Woka nya ta tso dedienɔnɔ ƒe teƒe aɖe si ƒe kekeme nye milimeta 22.9 ± milimeta 8.9, si megblẽa nu le ƒunukpeƒe siwo te ɖe wo nɔewo ŋu ŋu o hã ŋu. Tso blema ke la, woɖoa gɔmedzedze na ɖa si wotsɔ ɖoa ​​afɔkpodzi ƒe ke ƒe gbagbãwo me to infrapatellar mɔnu dzi, to patellar tendon la mama (transpatellar mɔnu) alo to patellar tendon stop ƒe akpa aɖe ɖeɖeɖa me (paratendinous mɔnu).

Semi-extension intramedullary nailing he susu geɖe le ƒuŋutinunyagbalẽ siwo woŋlɔ nyitsɔ laa me, eye Tornetta kple Collins do susua ɖa be woazã medial parapatellar mɔnu hena nail la ƒe ememe ƒoƒo ɖe semi-extension nɔnɔme me be woaƒo asa na intramedullary nail ƒe ta ƒe dodo ɖe ŋgɔgbe tibial cortex me.3 The use of a medial parapatellar approach for wokafui hã be woaƒo ati ɖe lãkusi me le semi-extension nɔnɔme me. Wokafu suprapatellar mɔnu zazã hena tibial intramedullary nailing kple intramedullary nail dede to patellofemoral joint me le semi-extended position me.

Wowɔa dɔa kple kloa si wobɔbɔ abe dzidzenu 15-20 ene, eye woɖea kloa le didiƒe si didi abe sentimeta 3 ene le abɔta ƒe kekeme abe asibidɛ ɖeka va ɖo eve ene. Womãa lãkusi eneawo me le mɔ didi nu eye woɖea lãkusi si me mekɔ o ɖe afɔkpodzi ƒe ƒunukpeƒea me. Wodea socket si me mekɔ o to patellofemoral joint me be woawɔ gegeɖeƒe le proximal anterior tibial cortex kple articular surface ƒe ƒoƒoƒe (Nɔnɔmetata 4).

Figure 4. ab Foto siwo woɖe le dɔwɔwɔ me siwo me (a) woma quadriceps tendon eye wotsɔ trocar la to patellofemoral joint me yi tibial entry point me; (b) afisi woage ɖo le axadzi le dɔwɔwɔ me

Wozãa 3.2 mm drill bit tsɔ nyaa afisi aŋea dze egɔme tsoe le C-abɔ ƒe mɔfiafia te. Wowɔ soket si me do le be woatsɔ atrɔ asi le teƒe siwo woge ɖo kple esiwo me woado le ŋu nyuie. Wowɔa amekoko susɔe siwo dometɔ aɖewoe nye reaming kple tibial nail insertion to socket la dzi.

VIÐE SIWO ATE ŊU: Afɔ ƒe nɔnɔme si keke afã ate ŋu akpe ɖe ame ŋu be woagbugbɔ aɖɔ gbagbãƒea ɖo, vevietɔ le gbagbãƒe siwo ƒe afɔkpodzi ƒe akpa etɔ̃lia te ɖe eŋu si bɔ eye wòle dzogoe dzi yi ŋgɔe me. , Nɔnɔme si keke ɖe enu afã ate ŋu aɖe teteɖeanyi ɖa le lãmeka si le abɔta ene ŋu eye wòakpe ɖe eŋu be woagbugbɔ aɖo afisi gbagbã le. , Semi-extended position suprapatellar mɔnu hã ate ŋu anye mɔnu bubu si wozãna ɖe infrapatellar mɔnu si wozãna tsã la teƒe (Nɔnɔmetata 5).

Figure 5. Foto si woɖe le dɔwɔwɔ me si ɖe abixɔxɔ le lãmeka falɛfalɛwo ŋu le infrapatellar nuto me fia abe dzesi na suprapatellar mɔnu le nɔnɔme si keke afã me ene.

Numekukuwo ɖee fia be suprapatellar mɔnu si wozãna tsɔ ƒoa tibial intramedullary nailing le semi-extended position me nye amekokomɔnu si le dedie eye wòwɔa dɔ nyuie. Ehiã be woawɔ dɔdamɔnu dodokpɔwo le etsɔme be woaku nu me geɖe wu le viɖe kple kuxi siwo le suprapatellar approach intramedullary nailing ŋu eye woada ɣeyiɣi didi ƒe emetsonu siwo do ƒome kple mɔnu sia kpɔ.

02. Gbugbɔ ɖo mɔ̃ɖaŋununya

Tibial intramedullary nail dede ɖeɖe dzaa menaa eƒe gbagbã dzi kpɔtɔna nyuie o; ele be woalé gbagbã dzi ɖeɖe kpɔtɔ nyuie me ɖe asi le reaming ƒe dɔwɔwɔ bliboa kple intramedullary nail dede me. Ðewohĩ asi hehe ɖeɖe dzaa mate ŋu ana woaɖe gbagbãƒea ƒe ŋutilã ƒe wɔwɔme dzi akpɔtɔ le eɖokui si ɣesiaɣi o. Nyati sia aƒo nu tso mɔnu vovovo siwo wozãna tsɔ ɖea nu dzi kpɔtɔna, siwo me womedea ame dzi boo o, kple esiwo wowɔna le gaglãgbe me.

-Closed reset aɖaŋu aɖaŋuɖoɖowo

Woateŋu awɔ nusiwo dzi woɖena kpɔtɔna ƒe mɔnu siwo wotu kple dɔwɔnu si ɖea nu dzi kpɔtɔna abe F-fracture reducer, si nye F-nɔnɔme ƒe nukpɔkpɔ dzi ɖeɖe kpɔtɔ ƒe mɔ̃ si woate ŋu atsɔ radiographicly transmissible si ɖɔa inversion/exversion angles kpakple medial/lateral translation ɖo (Fig. 6).

Fig. 6. F-nɔnɔme ƒe gbagbãnutsitike si woyɔ le amekoko me

Gake mɔ̃a ate ŋu ade nuteɖeamedzi gã aɖe lãmeka falɛfalɛawo dzi, eye ele be woaƒo asa na mɔ̃ sia si wotsɔ gbugbɔa nu ɖona la zazã ɣeyiɣi didi. Woate ŋu atsɔ reduction forceps hã ade ŋutigbalẽ me, abe alesi wòle le spiral kple oblique fractures gome ene. Woate ŋu atsɔ dɔwɔnu siawo awɔ dɔe le mɔ si sɔ na lãmeka falɛfalɛwo nu to lãɖeɖe suewo me (Nɔnɔmetata 7).

Figure 7. Percutaneous clamping be woagbugbɔ aɖo tibial fracture

Ele be woanɔ te ɖe aɖaŋu aɖe si dzi woato aɖe nusiwo agblẽ le lãmeka falɛfalɛwo ŋu ɣeyiɣi didi tso clamp dede me dzi akpɔtɔ dzi atia clamp ƒomevi kple afisi woatso amekokoa le (Nɔnɔmetata 8).

Fig. 8. Pointed repositioning forceps be woagbugbɔ aɖo tibial fracture

Retractors hã nye dɔwɔnu siwo bɔ siwo wozãna tsɔ gbugbɔa afɔkpodzia ƒe didime ɖoa te la dometɔ ɖeka. Zi geɖe la, wodaa wo ɖe titina eye woɖea wo ɖa tso teƒe si wòhiã be woatsɔ ɖa si le lãkusia me la aɖo. Woate ŋu aɖo traction pins siwo te ɖe wo nɔewo ŋu be woasrɔ̃ proximal blocking screw ƒe nɔnɔme, si wɔnɛ be woate ŋu aɖe gbagbãƒea dzi akpɔtɔ bɔbɔe ne intramedullary nail la nya ge ɖe eme ko.

Le go aɖewo me la, mɔxexeɖedɔléle nu ƒe mɔnu siwo wotu kple esiwo me womezãa nu boo aɖeke le o mesɔ gbɔ kokoko be woakpɔ ŋutilã ƒe wɔwɔme dzi ɖeɖe kpɔtɔ o. Le nɔnɔme mawo me la, ele be woabu mɔnu siwo dzi woato aɖe lãɖeɖe dzi akpɔtɔ ŋu eye woakpɔ lãkusi falɛfalɛ siwo ƒo xlãe dzi nyuie. Nusiwo ate ŋu agblẽ le mɔnu siwo wozãna tsɔ ɖea dɔlékuiwo dzi kpɔtɔna le gaglãgbe ŋu dometɔ aɖewoe nye amekoko ƒe nuveviwɔame bubuwo, si ate ŋu ana dɔlékuiwo xɔxɔ le amekoko teƒe nadzi ɖe edzi. Tsɔ kpe ɖe eŋu la, ʋu si yi teƒe si ʋu gbagbã le la ɖeɖeɖa kpee ate ŋu ana ʋu gbagbã ƒe afɔkua nadzi ɖe edzi.

-Mɔ̃ɖaŋununya na Incision kple Repositioning

Menye amekoko ƒe ʋuʋu dzi ɖeɖe kpɔtɔ ƒe mɔnuwo ɖea mɔ na amekoko ƒe aŋenu siwo woda ɖe teƒe nyuitɔ ko o, ke woɖea mɔ hã be woatsɔ aŋe suewo alo suewo asisi ɖe teƒe si wogbãe le be woalé gbagbã dzi ɖeɖe kpɔtɔ me ɖe asi le ɖaƒoƒo le lãkusi me.

Wozãa gavi siwo woyɔna be monocortical screws tsɔ blaa agbalẽviwo ɖe gbagbãƒe kakɛ siwo te ɖe wo nɔewo ŋu kple esiwo le didiƒe ŋu. Woléa aŋea ɖe te le alesi woɖea ɖa si le lãkusia me kple etsɔtsɔ dea afɔkpodzia me la katã me. Esi woda ɖa si le lãkusia me vɔ la, woɖea agbalẽvi la ɖa alo gblẽa wo ɖe teƒea be wòana xɔtunu si woɖo ɖi la nali ke nyuie wu (Nɔnɔmetata 9). Ne wogblẽ agbalẽvia ɖe teƒea la, ele be woaɖɔli lãkusi ɖeka ƒe gavi la kple lãkusi eve ƒe gavi la. Ele be woabu eŋu be woazãe le nɔnɔme tiatia siwo me ahiã be woawɔ dɔ na afɔkpodzi ƒe ke le gaglãgbe be woaɖe gbagbã dzi akpɔtɔ si dzi woda asi ɖo.

Figure 9. Open tibia fracture si me ƒu ƒe gbagbã sesẽ le eye ƒu ƒe gbagbã, cortical fixation ɖeka kple splint sue aɖe le fracture ƒe nuwuwu si gbã le splint la dzi ɖeɖe kpɔtɔ kple eɖeɖe le intramedullary nail fixation megbe

Taɖodzinu si le ɖa si xea mɔ na ɖa ŋue nye be wòana medullary cavity si le metaphyseal nutoa me la natsi. Wotsɔa ɖa siwo xea mɔ na nu la dana ɖe ƒunukpeƒe ƒe kakɛ kpui la me kple le nɔnɔme madeamedzia ƒe akpa si le ƒoƒom la dzi hafi wotsɔa ɖa si le lãkusia me la dana ɖe lãkusia me. Le kpɔɖeŋu me, alesi afɔkpodzi ƒe akpa etɔ̃lia si te ɖe eŋu ƒe gbagbã ƒe nɔnɔme gblẽnae nyea valgus kple ŋgɔgbe dzogoe. Be woaɖɔ valgus ƒe nɔnɔme madeamedzia ɖo la, woate ŋu atsɔ gavi si xea mɔ na nu la ade akpa si le proximal fracture fragment (si nye, deformity ƒe akpa si le ƒoƒom) me le anteroposterior mɔ nu. Wofiaa mɔ ɖa si le lãkusi me la tso titina, si wɔnɛ be valgus xea mɔ na wo. Nenema ke woate ŋu aɖu dzogoe ƒe nɔnɔme madeamedzi dzi ne wotsɔ gavi si xea mɔ na nu la de titina vaseɖe axadzi le megbekpa si le proximal block (si nye, deformity ƒe akpa si le ƒoƒom) (Nɔnɔmetata 10).

Figure 10. kpe asi ɖe tibial fracture ƒe gbugbɔgaɖoɖo ŋu to ɖa siwo xea mɔ na wo dede me

-Medullary ƒe kekeɖenudɔwɔwɔ

Ne wowu ƒu ƒe gbagbãƒea gbugbɔgaɖoanyi nu vɔ la, wotiaa medullary reaming be woatsɔ adzra ƒua ɖo be woatsɔe ade ƒua me. Wotsɔa mɔfiaka si ƒe nuwuwu nye bɔl la dea tibial marrow cavity me eye wòtoa afisi wògbã le, eye wotsɔa reaming drill la toa mɔfiaka si ƒe nuwuwu le bɔl la dzi. Woɖo kpe afisi mɔfiameka si ƒe nuwuwu le bɔl la ƒe nɔƒe dzi le C-arm fluoroscopy me be ele afɔkpodzi ƒe ƒunukpeƒea ƒe seƒe, eye mɔfiaka la nɔ titina nyuie le ŋgɔgbe kple axadzi siaa ƒe nukpɔkpɔwo me (Nɔnɔmetata 11).

Figure 11. fia mɔfiame ka ƒe nɔƒe le medullary cavity me le C-arm fluoroscopy dzi le ŋgɔgbe kple axadzi nɔnɔmewo me

Nya si ku ɖe medulla si keke ta kple esi mekeke o ŋu la nye nyaʋiʋli. Míexɔe se be amekola akpa gãtɔ siwo le Dziehe Amerika lɔ̃a abɔta ƒe lãkusi si keke ɖe enu le lãkusi me wu esi womekeke o. Gake woate ŋu azã ɖaƒoƒo si keke ta kple esi womekeke ɖe enu o siaa abe mɔnu siwo dzi woda asi ɖo siwo sɔ ene, eye woate ŋu akpɔ nu nyuiwo tso mɔnu eveawo siaa dzi.

-Locking screw ɖoɖo

Woɖoe be woazã gavi siwo ƒoa ƒu ɖe wo nɔewo ŋu le afɔkpodzi ƒe ke ƒe gbagbã me be woaxe mɔ ɖe kpuiƒe kple eƒe tɔtrɔ nyuie nu, si akeke dzesi siwo fia be woatsɔ aŋe aƒo ɖe afɔkpodzia me ɖe enu ayi akɔta ƒe ke ƒe gbagbã siwo te ɖe wo nɔewo ŋu wu kple esiwo le didiƒe wu siwo lɔ metaphysis ɖe eme. Le gbagbãƒe siwo ku ɖe metaphyseal nuto ŋu me la, gavi siwo ƒoa ƒu ɖe wo nɔewo ŋu va le vevie wu le axial alignment me léle ɖe asi me.

Kplu etɔ̃ siwo wotsɔ blaa wo nɔewo le wo nɔewo gbɔ na woƒe liƒo nyo ɖe edzi ŋutɔ, eye gavi siwo wotsɔ blaa wo nɔewo le dzogoe dzi ate ŋu ana woali ke wu gavi siwo wotsɔ blaa wo nɔewo bɔbɔe, si ate ŋu ana woate ŋu akpɔ xɔtuɖoɖo ƒe liƒo ma ke ne wotsɔ gavi ʋɛ aɖewo siwo wotsɔ blaa wo nɔewoe la nali ke. Dɔdaƒe ŋuti nyatakaka siwo ku ɖe gavi siwo wotsɔ blaa wo nɔewo ƒe xexlẽme kple woƒe ɖoɖo si hiã be woatsɔ alé afɔkpodzia ƒe ememe la ŋu gakpɔtɔ le sue.

Zi geɖe la, wozãa scope si wotsɔ bla ɖe intramedullary nail spike ŋu tsɔ dea proximal interlocking screws. Wotsɔa gavi siwo doa ka kple wo nɔewo le didiƒe dea asi faa le fluoroscopic mɔfiame te. Wokafui be woazã elektrikŋusẽ ƒe mɔfiameɖoɖo si kɔmpiuta kpena ɖe ame ŋu le tsɔ dea distal tibial interlocking screws (Nɔnɔmetata 12). Mɔnu sia ɖea mɔ be woatsɔ gavi siwo doa ka kple wo nɔewo le didiƒe ade eme keklẽŋusẽ manɔmee eye wokpɔe be enye mɔnu si woate ŋu awɔ eye wòde pɛpɛpɛ.

Figure 12.AB Locking screws to C-abɔ ƒe nukpɔsusu dzi; CD Locking screws to elektrikŋusẽ ƒe kɔmpiuta si kpena ɖe eŋu ƒe ʋuƒo dzi

Gavi siwo wotsɔ blaa wo nɔewo le teƒe si te ɖe wo nɔewo ŋu kple esiwo le didiƒe la ɖoɖo nye amekoko si le dedie eye ele be woatsɔ gavi siwo do ƒome kplii la ade eme le mɔ si sɔ pɛpɛpɛ eye wòasɔ na lãmeka falɛfalɛwo nu.

Lãmetsiŋusẽ ŋuti numekukuwo ɖee fia be afɔku gakpɔtɔ li be woaxɔ peroneal nerve palsy ne wotsɔ proximal medial to lateral oblique interlocking screws da ɖe wo nɔewo ŋu. Be woaɖe afɔku sia dzi akpɔtɔ la, ele be amekolawo nabu tomekuku na gaviawo ŋu le C-abɔ ƒe mɔfiafia te, eye C-abɔa ƒe dzogoe si me keklẽ le nanɔ tsitre ɖe drill bit ƒe yameʋua ŋu. Drill ƒe gege ɖe distal tibia ƒe cortex me ate ŋu asesẽ be woakpɔe to asikaka nyaŋuɖoɖo me, eye fibular ta ƒe tete ɖe eŋu ate ŋu ado viviti ɖe asikaka nukpɔkpɔa ŋu eye wòana amekolaa nasusu be 'le ƒu me' evɔ le nyateƒe me la, fibular ta la ge ɖe eme. Menye ɖeko wòle be woatsɔ drill si wowɔ graduate koe akpɔ screw ƒe didime o, ke ele be woadzidze goglomedzidzenu siwo sɔ hã. Ele be drill alo screw ƒe didimedzidzenu ɖesiaɖe si lolo wu milimeta 60 nana ɖikeke nanɔ ame ŋu be posterolateral protrusion, si ate ŋu ana peroneal nerve si bɔ la naɖo afɔku me be wòaxɔ abi.

Wodea ŋgɔgbe kple megbe ƒe ʋuƒo siwo doa ka kple wo nɔewo le didiƒe kple ŋkuléle ɖe ŋgɔgbe ƒe ahɔhɔ̃mekawo ƒe ƒuƒoƒo, tibialis ŋgɔgbe lãkusi, kple extensor digitorum longus ƒe ametakpɔkpɔ ŋu. Togbɔ be zi geɖe la, afɔku siwo le lãkusi falɛfalɛ siwo ƒo xlãe me la, ele be amekolawo nanya afɔku siwo le lãkusi falɛfalɛ siwo ƒo xlãe me. Le tibial stem ƒe gbagbã akpa gãtɔ gome la, screw eve siwo le proximal kple distal interlocking screws naa li ke nyuie. Afɔkpodzi ƒe gbagbã siwo te ɖe wo nɔewo ŋu kple esiwo le didiƒe ate ŋu aɖe vi ne wotsɔ gavi bubu siwo wotsɔ blaa wo nɔewoe de yameʋu vovovowo me be xɔtunu sia nali ke ɖe edzi (Nɔnɔmetata 13).

Nutata 13. Afɔkpodzi ƒe gbagbã geɖe, siwo wotsɔ gavi eve siwo do ƒome kple wo nɔewo le didiƒe kple esiwo te ɖe wo nɔewo ŋu ƒoƒo da dɔe, eye x-ray siwo wowɔ emegbe ɖee fia be gbagbãƒea ƒe dɔyɔyɔ.

-Fibular ƒe Fixation

Egbegbe ɖa siwo le lãkusi me ƒe nɔnɔme siwo me wotsɔa gavi siwo doa ka kple wo nɔewo le didiƒe kekea dzesi siwo fia be woatsɔ aŋe aƒo ɖe afɔkpodzia me ɖe enu be wòaxɔ proximal kple distal fractures siwo lɔ metaphyseal nuto la ɖe eme.

Wozã distal interlocking screw ƒe ɖoɖo vovovowo le numekukua me (screw 2 tso titina va ɖo axadzi tsɔ wu screw 2 siwo woda ɖe wo nɔewo dzi eye wo katã ƒe ƒuƒoƒo nye distal interlocking screw 3 tsɔ wu distal interlocking screw 1 ko). Le dɔnɔ siwo wowɔ fibular fixation kple tibial intramedullary nail fixation na gome la, reset si bu ƒe agbɔsɔsɔme ɖiɖi ŋutɔ. Dɔnɔ siwo katã ƒe 13 % le intramedullary nail fixation si me fibular fixation mele o la ɖee fia be dɔwɔwɔ vɔ megbe ƒe reset bu, ne wotsɔe sɔ kple 4 % le dɔnɔ siwo ƒe tibial nail fixation si fibular fixation mele o.

Le dodokpɔ bubu si tsɔ tibial intramedullary nail fixation ƒe dɔwɔwɔ sɔ kple fibular fixation kple tibial intramedullary nail fixation tsɔtsɔ sɔ kple fibular fixation manɔmee me la, dɔnɔ siwo wotsɔ fibular fixation kpe ɖe tibial nailing da dɔ na la ɖe ŋgɔyiyi fia le rotational kple inversion/eversion alignment me.

Míeƒo nya ta be adjunctive fibular fixation ɖoa tibial fracture dzi ɖeɖe kpɔtɔ gbɔ le distal tibia ƒe akpa etɔ̃lia ƒe gbagbã siwo wowɔ intramedullary nail fixation me eye wòlénɛ ɖe te. Gake abi ƒe kuxi siwo dona tso abi bubu siwo wotso le lãmeka siwo ŋu abi le ƒe teƒea ƒe kuxia gakpɔtɔ li. Eyata míeɖo aɖaŋu be woaɖɔ ŋu ɖo le fibular fixation si kpena ɖe ame ŋu zazã me.

03. Emetsonuwo

Intramedullary nailing fixation of tibial stem fractures ate ŋu ana nu nyuiwo nado tso eme. Woka nya ta tso alesi wotsɔa atitsoga ƒoa afɔkpodzi to lãkusi me ƒe dɔyɔyɔ ƒe agbɔsɔsɔme ŋu le numekuku vovovowo me. Ne wozã egbegbe nusiwo wotsɔ dea ame me kple amekokomɔnu siwo sɔ la, wole mɔ kpɔm be dɔyɔyɔ ƒe agbɔsɔsɔme agbɔ 90 %. Wokpɔ alesi tibial stem gbagbã siwo mete ŋu haya o le ɖa si wotsɔ ƒo ƒu ɖe lãkusi me megbe ƒe dɔyɔyɔ ƒe agbɔsɔsɔme nyo ɖe edzi ŋutɔ le esi wotsɔ ɖa evelia si keke ɖe enu le lãkusi me la ɖo ememe vɔ megbe.

Nusiwo do tso eme ƒe dodokpɔ le ƒe ɖeka le amekoko vɔ megbe ɖee fia be dɔnɔ siwo ade 44 % yi edzi ƒe dɔwɔwɔ ƒe seɖoƒewo nɔ woƒe akɔta si xɔ abi la ŋu, eye va ɖo 47 % yi edzi gblɔ nuwɔametɔnyenye si do ƒome kple dɔwɔwɔ le ƒe ɖeka le amekokoa megbe. Numekukua ɖee fia be dɔnɔ siwo wotsɔ atikutsetse ƒoƒo ɖe afɔkpodzi me da dɔ na la yi edzi le dɔwɔwɔ ƒe seɖoƒe gã aɖe le wo ŋu le ɣeyiɣi didi aɖe megbe. Ele be amekolawo nanya nya siawo eye woaɖo aɖaŋu na dɔnɔwo ɖe wo nu!

四 ƒe nya. Kuxi siwo dona tso dɔwɔwɔ vɔ megbe

01. Vevesese si do ŋgɔ na patellar

Anterior patellofemoral pain nye kuxi si bɔ le intramedullary nail fixation of tibial stem fractures megbe. Numekukuwo ɖee fia be dɔnɔ siwo ade 47 % le lãkusi me ƒoƒo vɔ megbe ate ŋu axɔ vevesese si do ŋgɔ na ʋuka, si ƒe nusi gbɔ wòtso gɔme bliboe o. Nusiwo ate ŋu akpɔ ŋusẽ ɖe edzi ate ŋu anye nuveviwɔame kple atikewɔwɔ na ƒunukpeƒetetedɔ, abixɔxɔ le saphenous nerve ƒe infrapatellar alɔdzea ŋu, ata ƒe lãmekawo ƒe gbɔdzɔgbɔdzɔ si nye evelia le vevesese si do ƒome kple ahɔhɔ̃mekawo ƒe dɔwɔwɔ nutsitsi ta, fibrosis of the fat pad leading to impingement, reactive patellar tendonitis, bending strain from intramedullary atitsotso ɖe afɔkpodzi ƒe akpa si te ɖe eŋu dzi, kple ɖaa ƒe nuwuwu si te ɖe eŋu ƒe dodo.

Esi wonɔ nu srɔ̃m tso nusi gbɔ vevesese si do ŋgɔ na ʋukawo ƒe vevesese tsona le lãkusi me ƒoƒo vɔ megbe ŋu la, wotsɔ transpatellar tendon mɔnu sɔ kple parapatellar mɔnu. Ðewohĩ transpatellar tendon mɔnu la do ƒome kple klo ƒe vevesese si sɔ gbɔ wu le dɔwɔwɔ vɔ megbe. Gake dɔdamɔnu ŋuti nyatakaka siwo woxɔ le vome siwo wokpɔ mɔ na meɖe vovototo gã aɖeke fia le transpatellar tendon mɔnu kple parapatellar mɔnu dome o.

Kakaɖedzi mele ememe fixation ɖeɖeɖa tiatiatɔe ƒe dɔwɔwɔ ŋu be woatsɔ akpɔ prepatellar vevesese gbɔ le tibial intramedullary nailing megbe o. Míeɖo aɖaŋu be woabu intramedullary tibial nail ɖeɖeɖa ŋu ne woate ŋu ade dzesi mɔ̃ aɖe si gbɔ wòtso, abe ɖa si do ɖe gota alo gavi si do ɖe gota si do ƒome kple wo nɔewo ene. Gake viɖe si le tibial intramedullary nail removing ŋu le dɔnɔ siwo ŋu dzesiwo le ŋu gakpɔtɔ nye ɖikeke.

Le dɔwɔwɔ vɔ megbe ƒe vevesese si do ŋgɔ na ƒunukpeƒewo gome la, womete ŋu ɖe nusi gbɔ vevesesea tso fia kɔte le dɔdamɔnu ŋuti numekuku gbãtɔ si wowɔ le abɔta ƒe ɖa si le lãkusia me ƒe ƒoƒo ɖe lãkusi me le nɔnɔme si keke afã me ŋu o. Eyata ehiã be woawɔ dɔdamɔnu ŋuti numekuku gã siwo me woakplɔ wo ɖo ɣeyiɣi didi be woatsɔ aɖo kpe ŋusẽ si ɖa si wotsɔna ƒoa ɖa le lãkusi me le suprapatellar mɔnu me kpɔna ɖe amekoko megbe vevesese si do ŋgɔ na lãkusi dzi dzi.

02.Amewɔwɔ vɔ megbe ƒe ɖoɖowɔwɔ nyuie o

Ƒumeŋuɖui si dzɔna le afɔku megbe gakpɔtɔ nye kuxi vevi aɖe le tibial stem ƒe gbagbãwo dada kple intramedullary nailing megbe. Biomechanical numekukuwo ɖee fia be tibia ƒe masɔmasɔ ate ŋu ana tɔtrɔ gãwo nava le kadodo ƒe nyaƒoɖeamenu le afɔkpodzi kple klo ƒe ƒunukpeƒe siwo te ɖe wo nɔewo ŋu me.

Dɔdamɔnu ŋuti numekuku siwo da dɔdamɔnu kple nɔnɔmetatawo me tsonu siwo nɔa anyi didi le afɔkpodzi ƒe ke ƒe gbagbã megbe kpɔ la na nyatakaka siwo tsi tre ɖe wo nɔewo ŋu le akɔta ƒe masɔmasɔ ƒe emetsonuwo ŋu, eye womeƒo nya ta nyuie aɖeke vaseɖe fifia o.

Nyatakaka siwo ku ɖe dɔwɔwɔ vɔ megbe ƒe masɔmasɔ le afɔkpodzi ƒe ƒoƒo ɖe lãkusi me megbe ŋu gakpɔtɔ le sue, eye wogblɔ be ame ʋɛ aɖewo koe li. Dɔwɔwɔ vɔ megbe ƒe tɔtrɔ gbegblẽ gakpɔtɔ nye kuxi si bɔ le tibial intramedullary nailing me, eye tibial intramedullary nailing me dzodzro le dɔwɔwɔ me gakpɔtɔ nye kuxi. Vaseɖe fifia la, womeɖo dɔdamɔnu dodokpɔ alo nɔnɔmetatawo ɖeɖe ƒe mɔnu aɖeke anyi be wòanye sikadzidzenu si woatsɔ anya afɔkpodzi ƒe tɔtrɔ le dɔwɔwɔ me o.CT dodokpɔ me dzodzro ɖee fia be ʋuʋudedi ƒe agbɔsɔsɔme le afɔkpodzi ƒe ʋuʋu le lãkusi me megbe ate ŋu asɔ gbɔ abe 19 % va ɖo 41 % ene. Vevietɔ la, edze abe gotagome tɔtrɔ ƒe nɔnɔme madeamedziwo bɔ wu ememe tɔtrɔ ƒe nɔnɔme madeamedziwo ene. Woka nya ta be dɔdaƒe ƒe dodokpɔ be woatsɔ akpɔ dɔwɔwɔ vɔ megbe ƒe tɔtrɔ gbegblẽe mesɔ o eye wòɖee fia be kadodo boo aɖeke mele wo kple CT ƒe dodokpɔ dome o.

Míexɔe se be masɔmasɔ gakpɔtɔ nye kuxi si nɔa anyi ɣeyiɣi didi le afɔkpodzi ƒe ke ƒe gbagbã siwo wotsɔ atikpoa ƒe lãkusi si wotsɔ ƒo ƒu ɖe lãkusi me da dɔe me. Togbɔ be nyatakaka siwo tsi tre ɖe wo nɔewo ŋu ku ɖe ƒomedodo si le masɔmasɔ kple dɔdamɔnu kple nɔnɔmetatawo me tsonu dome ŋu hã la, míeɖo aɖaŋu be ele be amekolawo nadze agbagba be yewoaɖo ƒu gbagbãwo ƒe ŋutilã ƒe wɔwɔme ɖe ɖoɖo nu be woate ŋu aɖu tɔtrɔ sia dzi eye woakpɔ emetsonu nyuitɔwo.

五 ƒe nya. Nyanuwuwuw

Static locking expanded medullary intramedullary nailing gakpɔtɔ nye atikewɔwɔ si wozãna ɖaa na tibial stem fractures siwo woɖe ɖa. Afisi woage ɖo nyuie gakpɔtɔ nye amekokoa ƒe akpa vevi aɖe. Wobua suprapatellar mɔnu si le semi-extended position me be enye mɔnu si le dedie eye wòwɔa dɔ nyuie, eye ele be numekuku siwo woawɔ le etsɔme nadzro afɔku kple viɖe siwo le dɔwɔwɔ sia me la me geɖe wu. Ele be amekola si le ekpɔm la nanya egbegbe mɔnu siwo wozãna tsɔ trɔa asi le ame ƒe teƒe bubuwo ŋu nyuie. Ne womate ŋu awɔ ŋutilã ƒe gbagbã ƒe sɔsɔ to mɔnu si wotu nu o la, ele be woabu mɔnu siwo dzi woato aɖe lãɖeɖe dzi akpɔtɔ ŋu. Woate ŋu akpɔ dɔyɔyɔ ƒe agbɔsɔsɔ nyui si wu 90 % ne wotsɔ ati ƒo ɖe lãkusi me si keke kple esi womekeke o siaa. Togbɔ be dɔnɔwo ƒe dɔyɔyɔ nyuie hã la, dɔwɔwɔ ƒe gbɔdzɔgbɔdzɔ gakpɔtɔ nɔa wo ŋu ɣeyiɣi didi. Vevietɔ, prepatellar vevesese gakpɔtɔ nye nyatoƒoetoto si bɔ le tibial intramedullary nailing megbe. Tsɔ kpe ɖe eŋu la, tɔtrɔ si mesɔ o le tibial fixation ememetɔ megbe gakpɔtɔ nye kuxi si bɔ.

Nusiwo ŋu woke ɖo

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