Nailing Intramedullary Femoral - Yadda Ake Zaɓan Mafi kyawun Wurin Shigarwa?

Gabatarwa

Za a iya gano ci gaban maganin karaya na mata tun cikin shekarun 1940 lokacin da Kuntscher ya gabatar da dabarar ƙusa intramedullary ta rufe. Amfani da kusoshi na intramedullary (IMNs) a cikin karyewar mata ya zama ma'auni na kulawa a cikin ƴan shekarun da suka gabata, da haɓakawa a halin yanzu Nailing intramedullary da ci gaba a cikin fasahohin tiyata sun ba da izinin karuwa mai yawa a cikin yin amfani da ƙusa intramedullary na femur.

Conservative jiyya na femoral kara karaya ana amfani ne kawai a cikin wani sosai kananan adadin marasa lafiya da gagarumin contraindications ga sa barci da kuma tiyata, da kuma babban jiyya ya kasance m gyarawa. Game da aikin tiyata na waɗannan karaya, akwai zaɓuɓɓuka da yawa da ake da su, ciki har da ƙusa intramedullary, gyaran farantin screw, da gyaran waje. Idan aka kwatanta da sauran zaɓuɓɓukan tiyata, ƙusa intramedullary shine yanayin tare da mafi ƙarancin wahala da ƙimar waraka mafi girma, kuma ana ƙara yin amfani da shi sosai a aikin asibiti.

Kyakkyawan fahimtar yanayin jikin mace mai kusanci, da samar da jini ga kan femoral da kuma jikin tsokoki na hip na iya kara yawan nasarar ƙusa intramedullary don karyewar femoral. Sabanin haka, zaɓin wurin shiga ya dogara da dalilai da yawa, gami da ƙirar ƙusa na intramedullary, wurin karyewa, ɓarke ​​​​comminution, da abubuwan haƙuri (misali, polytrauma, ciki, da kiba). Ba tare da la'akari da wurin da aka zaɓa ba, samun madaidaicin wurin shiga yana da mahimmanci don kula da raguwa mai yawa yayin shigar da ƙusa na intramedullary yayin rage haɗarin rikitarwa.

Jiki na mata

1.Jini ga kan femoral

Shugaban femoral yana karɓar wadatar jijiyoyin jini daga manyan arteries 3. Jijiyoyin mata masu juyi na gefe (tare da rassan 3-4), jijiyar obturator, wanda ke ba da ligament zagaye, da kuma tsaka-tsakin tsaka-tsaki na mata (Fig. 1), wanda kuma ya ba da wani jirgin ruwa mai hawan hawan sama wanda ke daskarewa tare da na'urar rotator femoral na gefe kuma yana ba da yankin trochanteric mafi girma.

2.Anatomy Of The Hip Muscles

Lokacin yin ƙusa intramedullary na femur, kyakkyawar fahimtar tsokoki a cikin yankin da ke kewaye da rotor yana da mahimmanci don hana raunin da ba dole ba. Gluteus medius tsoka ya samo asali ne daga ilium kuma ya ƙare a gefen gefe na mafi girma trochanter, yayin da gluteus minimus tsoka kuma ya samo asali ne daga ilium kuma ya wuce a kan gefen baya na haɗin gwiwa na hip don ƙare a gefen baya na mafi girma trochanter (Figures 2 & 3). Duk waɗannan tsokoki suna aiki azaman masu haɓaka cinya da masu juyawa na ciki na hip. Sabili da haka, lalacewa ga waɗannan tsokoki yayin shigar da ƙusa na intramedullary na mata na paracentric zai haifar da rauni mai ƙarfi da kuma gait Trendelenburg, wanda ke da mummunar tasiri ga farfadowa da sakamakon haƙuri.

Hoto 2. Anatomy na tsokoki a kusa da haɗin gwiwa na hip

Hoto 3. Yankin abin da aka makala tsoka na mata na kusa

Daidaici na Femoral Intramedullary Nail

Yawancin karatu na baya-bayan nan sun bincika mafi kyawun wurin shigarwa don ƙusa na mata na paracrine. Zaɓuɓɓukan wurin shigar ƙusa sun haɗa da mafi girma trochanter da pyriform fossa, kowanne tare da alamunsa da rikice-rikice masu alaƙa (Table 1).

Tebur 1.Farawar maki da yiwuwar haɗari na paracrine da retrograde femoral nailing
bambancin	layi daya intramedullary ƙusa		retrograde intramedullary ƙusa
	rotor	pyriform fossa (anatomy)
jirgin kambi	Vertex na mafi girma trochanter da kuma nuna tsaka-tsaki zuwa ga rami medullary	junction na mafi girma trochanter da femoral wuyansa	tsakiya na intercondylar fossa (anatomy)
jirgin sama sagittal (math.)	Layi tsakanin tsakiyar mafi girma trochanter da tsakiyar bargo na femur	pyriform fossa (anatomy)	PCL 1.2 cm a gaba zuwa wurin farawa na mata, yana nuni zuwa ga rami na medullary.
fallasa	Ƙungiya masu satar hip-daga tasha rauni	Rashin isasshen jini ga kan femoral da tsokar juyawa na waje na hip	Rashin kulawa na iya haifar da PCL
PCL: ligament na baya

1.Babban wurin shigar allura na rotor

An kwatanta mafi girma trochanter a matsayin mafi m trapezoidal kasusuwa protuberance located a gefen gefen wuyan femoral, wanda samansa yana ba da abin da aka makala ga gluteus medius na gefe da tsokoki na gluteus minimus na gaba (Figures 2 da 3). Ko da yake wannan ƙaramin alamar ƙashi ne, gano madaidaicin wurin farawa lokacin yin IMN na mata na iya zama bambanci tsakanin samun sakamako mai gamsarwa ko mara kyau lokacin da ake mu'amala da karaya ta mace.

Yin bitar wallafe-wallafen na yanzu don bayanin ma'anar shigar mata, mun sami rashin cikakkiyar ma'anar yanayin jiki don madaidaicin shigar mata na IMN.Bharti et al. ya bayyana ma'anar shigarwa daga koli mai girma na mafi girma a matsayin mai tsaka-tsaki zuwa ga rami mai zurfi a cikin matsayi na orthostatic, kuma a matsayin cibiyar tsakiya mafi girma a cikin layi tare da tsakiyar ƙwanƙwasa na mata a matsayi na gefe (Fig. 4), da kuma bayanin madadin mafi girma trochanter ra'ayi a kan wani ra'ayi na gefe daya a tsakanin ra'ayi na baya-bayan nan. da na baya kashi biyu bisa uku na rotor.Georgiadis et al. ya bayyana wurin shigar allura a matsayin mafi girman gefen gefen mafi girma na rotor.

HOTO 4. Intraoperative orthostatic da kuma ra'ayi na gefe na hip suna nuna madaidaicin wurin shiga don ƙusa intramedullary na mata na mata na mafi girma trochanter. '*' yana nuna ma'aunin shigar farce ta intramedullary.

Binciken da aka yi kwanan nan a cikin wallafe-wallafen ya nuna cewa koli na mafi girma trochanter shine madaidaicin farawa don samun mafi kyawun layi na karfi, kuma rashin daidaituwa mara kyau saboda nakasar juzu'i sau da yawa yakan faru lokacin da ma'anar shigarwa ta canza fiye da 2 mm a gefe zuwa mafi girma trochanter. Har ila yau, wannan binciken ya jaddada cewa madaidaicin shigarwa na baya yana haifar da ƙaura ta gaba, yayin da tsaka-tsakin tsaka-tsakin zai iya haifar da shinge mai nisa ya koma baya. Sabanin haka, wani binciken ya nuna cewa a cikin ɓarna na intertrochanteric femur, abin da ya faru na ƙusa na intramedullary ya kasance mafi girma tare da maƙallin maɗaukaki wanda ya kasance a gefe zuwa gefen gaba fiye da ma'auni wanda yake kusa da tsaka-tsaki da na baya.

Ana amfani da mafi girman ma'aunin pinning mafi girma a cikin marasa lafiya masu kiba, kuma wannan hanya ba ta da buƙatar fasaha ta fasaha, tana ba da ƙarancin lokacin aiki da ƙarancin haɗarin rikitarwa fiye da madaidaicin pyriform fossa.

CIGABA: Ciwon ciki da rikice-rikice na ƙusa intramedullary na mata tare da mafi girman ma'anar trochanteric an tattauna a cikin wallafe-wallafe da yawa. Ɗaya daga cikin waɗannan, yawanci yana da alaƙa da fasaha na ƙusa, raunin da likita ya haifar. A cikin ɓarna na mata na intertrochanteric, wurin shiga da ke a gefe da gaba zuwa ga mafi girma trochanter zai iya haifar da raguwa na tsakiya fiye da hanyar shigarwa kusa da gefen tsakiya.

Wani abin da ya dace da shi shine saboda raunin da ya faru na nama mai laushi, musamman ga rassan ƙwanƙwasa na tsakiya na rotator femoral artery da kuma tsokoki na tsokoki, amma waɗannan raunin da ya faru ba su da yawa idan aka kwatanta da ƙusa na shigarwa na pyriform fossa. Bugu da kari, abin da ya faru na ischemic necrosis na femoral kai tare da koli na mafi girma trochanter kamar yadda ake tunanin wurin shiga ya zama ƙasa da ƙasa, tare da binciken da aka ba da rahoto a matsayin ƙasa da 0.3%.

Idan akai la'akari da lokacin intraoperative da bayyanar fluoroscopic, ma'anar lokacin aiki shine mintuna 90.7 don mafi girman shigarwar trochanteric idan aka kwatanta da mintuna 112.7 don rukunin shigarwar fossa mai siffar pear, yayin da lokacin fluoroscopic ya kasance 5.88 seconds don babban rukunin shigarwar trochanteric da 10.08 seconds don madaidaicin ma'aunin pear, idan aka kwatanta da fossa mai siffar pear.

Hasashen haƙuri kuma ya kasance muhimmiyar mahimmanci yayin yanke shawara akan madaidaicin ƙusa na intramedullary, kamar yadda farkon aikin dawo da aiki (kamar yadda aka tantance ta gwajin kujerar kujera da gwajin tsayin lokaci) ya fi kyau a cikin marasa lafiya a cikin watanni 6 bayan aikin tiyata don mafi girman shigarwar trochanteric idan aka kwatanta da ƙusa ƙusa na pyriform fossa, amma wannan bambancin bai kasance mai mahimmanci ba a cikin watanni 12. Kodayake mafi girma wurin samun damar shiga trochanteric yawanci ana danganta shi da raguwar ƙwayar nama mai laushi saboda wurin da yake, har yanzu yana iya haifar da rauni ga ƙungiyar tsoka mai ɓarna, kamar yadda Ergiş et al ya nuna. Sun gano cewa an rage ma'auni mai ƙarfi da ƙarfin satar hip a cikin marasa lafiya tare da mafi girman kututturen shigarwar trochanteric idan aka kwatanta da kulawar lafiya. Bugu da ƙari, binciken su ya ba da rahoton raguwa mai yawa na ƙarfin masu sace hip, masu sassauƙa da masu juyawa na ciki / waje idan aka kwatanta da gefen da ba a yi aiki ba.

2. Lu'u-lu'u fossa wurin shiga

Fossa na tsokar pyriformis wani muhimmin alamar anatomical alama ce da aka gano a matsayin ɗaya daga cikin wuraren shigarwa don ƙusa na intramedullary na mata na paracentesis. ya lura cewa fossa na tsokar pyriformis ba nau'in 'pear' ba ne ko abin da aka makala tsokar pyriformis. tsokar tsoka tana haɗawa da ƙaramin yanki a ƙarshen mafi girma trochanter, yayin da pyriform fossa shine baƙin ciki a gefen tsakiya na babban trochanter kuma shine abin da aka makala na tsokar carpi radialis brevis tsoka. Marubutan sun kammala cewa tsokar pyriform da pyriform fossa abubuwa ne daban-daban guda biyu kuma abin da ake kira pyriform fossa ya kamata a kira shi 'rotor' ko 'occlusal' fossa don tsabta da daidaiton jiki. Sun ba da shawarar cewa bayan nazarin cis-femoral sun ba da shawarar cewa a sake dawo da ainihin kalmar 'rotor fossa' a cikin wallafe-wallafe maimakon 'pyriform fossa' bayan sun yi nazarin kalmomi na wurin shigar da parafemoral. Ko da yake abubuwan da ke cikin waɗannan karatun guda biyu suna da daraja sosai, don sauƙin kwatantawa da kuma hana rudani tare da mafi girman shigarwar trochanteric, har yanzu za mu yi la'akari da wannan shigarwa a matsayin wurin shigarwa na pyriform fossa.

Yawancin karatu a cikin wallafe-wallafen na yanzu sun bayyana daidai daidai wurin shigar da fossa pearly don kusoshi na mata na intramedullary.Georgiadis et al. bayyana wurin shigarwar pearly fossa a matsayin yanki na abin da aka makala na extensor carpi radialis brevis tsoka a cikin ciki a gindin wuyan mata (Fig. 5). Har ila yau, marubutan sun jaddada cewa wurin shiga da ke da nisa ko kuma ya yi nisa a ciki zai iya ƙara haɗarin fashewar wuyan mata, kuma lokacin da wurin shiga ya yi nisa a baya, za a iya samun babban haɗari na ischemic necrosis, wanda ya fi girma a cikin matasa marasa lafiya.

Hoto 5. Ra'ayi na gaba na gaba na hip yana nuna madaidaicin wurin shiga don pyriform fossa retrograde femoral intramedullary ƙusa. The '*' yana nuna wurin farawa na ƙusa na intramedullary.

Harper et al. buga wani binciken na 14 kungiyoyin cadaveric femurs na mutum a cikin 1987 a cikin abin da suka kimanta wurin da intramedullary jagora fil da kuma mafita na intramedullary ƙusa gabatar distally da proximally a cikin wani retrograde fashion daga intercondylar daraja na femur. Sun kammala cewa wurin shigarwa na pyriformis paramedian intramedullary ƙusa yana samuwa a cikin haɗin gwiwa na mafi girma trochanter tare da wuyan mata, dan kadan a gaba ga pyriformis occult. An sake tabbatar da wurin shigar da Gausepohl et al. A cikin wani binciken cadaveric, sun gano madaidaicin wurin shiga don ƙusa intramedullary na mata tare da gefen tsakiya na mafi girma trochanter overlying pyriformis tendon. Bugu da ƙari kuma, a cikin binciken cadaveric ta Labronici et al. An kwatanta fossa na tsokar pyriformis a matsayin yanki mai haske mai siffar pear wanda ya dace da tsakiyar tsakiya na kogin intramedullary na mata a cikin jirgin sama na coronal.

Wurin samun damar pyriform fossa yana da wasu takamaiman rashin lahani saboda a zahiri yana da ƙalubale idan aka kwatanta da mafi girma wurin samun damar trochanter, musamman a cikin marasa lafiya masu kiba. Bugu da kari, mafi kyawun wurin shiga wurin shigar allurar fossa mai siffar pear yanki ne kunkuntar wuri, yana mai da shi mafi ƙalubale don gano wuri. Misali, madaidaicin wurin farawa na gaba akan wuyan mata zai haifar da matsanancin damuwa da yawa da kuma ƙara haɗarin fashewar cortical na baya, musamman idan wurin farawa ya wuce 6 mm gaba da fossa. Bugu da ƙari, bambance-bambancen ilimin halittar jiki na iya hana daidaitaccen wurin shigarwa, musamman ma idan ɗan gajeren gajere na waje yana da girma ko kuma rotor yana fitowa, yana haifar da wani wurin shigarwa wanda ke da tsaka-tsakin tsaka-tsaki da kuma hadarin fashewar wuyan mata.

CIGABA: Ta hanyar kwatanta 38 mafi girma trochanteric shigarwa shafukan tare da 53 pearly fossa shigarwa shafukan for femoral intramedullary ƙusa, Ricci et al gano cewa pearly fossa rukuni na da 30% tsawo aiki lokaci da kuma 73% tsawon fluoroscopy lokaci. An tabbatar da waɗannan binciken ta Bhatti et al. lokacin kwatanta wuraren shigar allura guda 2.

Game da rauni mai laushi mai laushi, akwai haɗari mafi girma na rauni mai laushi a cikin mashigar pyriformis idan aka kwatanta da interosseous neuromuscular a mafi girman shigarwar allurar trochanteric. Dora et al. kimanta 16 manya cadaveric femurs don raunin nama mai laushi ga tsokar pyriformis da fil ɗin shigarwa na rotor. Sun gano cewa ko da yake pyriformis fossa ya kasance mafi kyaun geometrically, ya haifar da mummunar lalacewa ga samar da jijiyoyin jini ga shugaban femoral da kewaye da tsokoki da tendons. An sake tabbatar da waɗannan binciken ta hanyar binciken cadaveric ta Ansari Moin et al. WHO ta kuma kwatanta wuraren shiga biyu. Sun lura cewa gyare-gyaren ciki na ƙusa da ke farawa a tsokar pyriformis ya fi iya lalata masu sace hip da kuma masu juyawa na waje. Bugu da ƙari, an sami lalacewa ga jijiya mai jujjuyawar mata ta tsakiya a duk lokuta (Table 2).

Tebur 2. Takaitacciyar raunin nama mai laushi a wuraren shigar allura daban-daban
bambancin	Pyriform fossa wurin shiga (n=5)	Babban wurin ciyarwar rotor (n=5)
laushi mai laushi
gluteus medius tsoka (anatomy)	5	1
gluteus medius tendon	0	4
raunin jijiya
Gluteus minimus (anatomy)	3	0
pyriformis tsoka (a saman kashin baya)	3	3
obturator internus (anatomy)	1	0
latissimus dorsi tsoka (anatomy)	3	0
Tasoshin jini da capsules na haɗin gwiwa
MFCA Deep Branches	4	0
MFCA Shallow Branch	4	0
articular capsule (na haɗin gwiwa kamar gwiwa a cikin jiki)	1	0
MFCA: Jijiyoyin mata na tsaka-tsaki.

Kwanan nan, Bharti et al. yayi nazari akan hadarin da ke tattare da kusoshi na intramedullary na mata a mafi girma wurin shigarwar trochanteric da wurin shigarwar fossa pearly kuma ya sami haɗari masu rikitarwa irin su raunin waraka kuma ya taƙaita su kamar haka (Table 3).

Tebura 3. Pyriform fossa wurin shiga da mafi girman maƙarƙashiyar maƙarƙashiya na mata
rikitarwa	Piriformis sinus batu na allura	Babban wurin saka trochanter
Kamuwa da cuta	6.7	3.3
Malunion	20	13.3
Jinkirta waraka	20	13.3
Ƙaƙwalwar hip motsi	20	33.3
Motsin gwiwa iyaka	6.7	6.7
Bambancin tsayin gaɓa	13.3	20
Rigar wutsiya tana fitowa sama da bawon kashi	13.3	20
Karya wuyan mata na ciki	10	0
Karaya mafi girma	0	3.4
Femoral kai necrosis	6.7	0

Retrograde femoral intramedullary nailing

Ƙayyade madaidaicin shigarwar da ya dace don retrograde femoral intramedullary nailing zai taimaka wajen cimma nasarar daidaitawa mafi kyaun gyare-gyare, tsayi, da juyawa yayin da yake rage lalacewar guringuntsi na guringuntsi, tsohuwar ƙwayar ƙwayar cuta (ACL), ligament na baya (ACL), da kuma rauni mai laushi (Table 1). Kwanan nan, an sami karuwar sha'awa ga retrograde femoral intramedullary nailing tare da manufar rage matsalolin da ke hade da kusoshi na paracromial, ciki har da ciwon hip, heterotopic ossification, rauni na adductor, da ciwon jijiyar jijiyoyi, wanda aka yi la'akari da ƙananan ƙwayar cuta idan aka kwatanta da incisional ragewa da kuma kulle ƙusoshin femoral na ciki na ciki na distalc plating. femoral kara. Bugu da ƙari, shaidu na baya-bayan nan sun nuna cewa lokacin da waɗannan kusoshi na intramedullary suka sake komawa daidai, ba za a iya buƙatar kusoshi na kusa ba. da Bisaccia et al. a cikin maganin karaya mai nisa na kashi ɗaya bisa uku na mata ta amfani da kulle-kulle da kusoshi na retrograde intramedullary. Don haka, yin amfani da ƙusa na femoral retrograde ya zama sananne kuma an yarda da shi sosai.

Ana iya samun bayanai da yawa na madaidaicin wurin shiga don retrograde femoral intramedullary nailing a cikin wallafe-wallafe. Yawancin karatu sun gano madaidaicin shigarwa don ƙusa na mata na retrograde a matsayin 1.2 na gaba zuwa asalin mata na ligament na baya.

cm (a layi daya tare da rami na medullary) da kuma tsakiyar fossa intercondylar (Hoto 6).

HOTO 6. Intraoperative orthostatic da kuma ra'ayi na gefe na gwiwa yana nuna madaidaicin shigarwa don ƙusa intramedullary femoral femoral. '*' yana nuna farkon farcen intramedullary.

Ko da yake babu cikakkiyar ma'ana don retrograde femoral intramedullary nailing, an bayyana alamun dangi da yawa. Waɗannan sun haɗa da marasa lafiya na polytrauma, marasa lafiya marasa lafiya, marasa lafiya masu juna biyu, ɓangarorin ɓangarorin femoral na mata biyu, ɓangarorin ipsilateral femoral da acetabular / pelvic fractures ko ƙwanƙwasa wuyan femoral, da ipsilateral femoral stem da tibial fractures. Yawancin waɗannan alamun suna da alaƙa da sauƙi na matsayi na haƙuri da kuma rigakafin raunukan tiyata da yawa a cikin kusanci.

A gefe guda, cikakkun abubuwan da ke haifar da ƙusa na intramedullary na mata sun haɗa da toshewar tashar intramedullary na retrograde ta hanyar dasa shuki da buɗewar faɗuwar femur mai nisa. Abubuwan da ke da alaƙa sune karaya da ke tsakanin 5 cm na ƙaramin ɗan ƙaramin ƙarfi, wahalar samun damar shiga mafi kyaun wurin shiga saboda jujjuyawar gwiwa na ƙasa da digiri 45, kafin kamuwa da cuta na gwiwa wanda zai iya haifar da haɗarin yaduwa zuwa tushe na femoral, raunin nama mai laushi a kusa da gwiwa, da raunin intra-articular na ƙwanƙwasa da matsananciyar matsananciyar rauni.

Matsaloli: Yawancin rikice-rikice na retrograde ƙusa na mata suna da alaƙa da rashin kulawa, musamman madaidaicin wurin shiga. A cikin jirgin sama na sagittal, madaidaicin shigarwa na gaba zai haifar da fassarar karaya ta baya, lalacewar farfajiyar articular, da yuwuwar ƙusa ƙusa a kan patella lokacin da aka murƙushe gwiwa. A gefe guda, idan wurin shigarwa ba shi da kyau a matsayi na baya, wannan zai iya haifar da haɗari mafi girma na rauni ga asalin ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar cuta.

Hutchinson et al. ya bayyana rikice-rikicen da ke da alaƙa da madaidaicin wuraren shiga jirgin sama na coronal. Sun gano cewa tsaka-tsakin tsaka-tsakin tsaka-tsakin tsaka-tsakin tsaka-tsakin ya haifar da nakasar baya tare da fassarar karaya ta baya, yayin da mai wuce gona da iri ya haifar da nakasar tsaka-tsaki da fassarar tsaka-tsaki.Sanders et al. ya ruwaito cewa zaɓar wurin farawa na tsakiya wanda ya kasance 2 cm ko fiye daga tsaka-tsakin tsaka-tsakin ya haifar da raguwa na tsaka-tsakin tsaka-tsakin tsaka-tsaki wanda aka lalata saboda lokacin lankwasawa na isthmic na baya na raguwa wanda ya haifar da raguwa mara kyau na baya.

Sauran rikice-rikicen da ke da alaƙa da retrograde mai bin ƙusa na mata sun haɗa da ciwon gwiwa, taurin kai, ciwon gwiwa na heterotopic, da samuwar jiki kyauta na gwiwa.

Kammala

Ko da yake kowace dabarar ƙusa ta intramedullary tana da madaidaicin nuni, zaɓin wacce dabarar ƙusa ta intramedullary don amfani da ita wajen maganin karaya ta mata yawanci ya dogara da fifikon likitan fiɗa. Lokacin yin ƙusa intramedullary na femur, samun madaidaicin wurin shigarwa don nau'in ƙusa da aka yi amfani da shi don gyarawa ana buƙatar samun sakamako mai nasara. Sanin ilimin halittar jiki na gida da aikin hoto zai taimaka wa likitan fiɗa yin aikin da ya dace na fasaha yayin da yake rage haɗarin rikice-rikice masu alaƙa. Bugu da ƙari, a cikin hanyoyin ƙusa intramedullary, kiyaye raguwa abu ne mai mahimmanci don hana ɓarna da ɓarna ko rashin haɗuwa da karaya.