Karyawar tibial, dabarar ƙusa intramedullary suprapatellar

Dabarar ƙusa ta intramedullary don karyewar tibial: ta hanyar suprapatellar, tsarin transarticular tare da ƙwanƙwasa gwiwa a 20-30 ° da takamaiman bututu mai kariya don kare tsarin intra-articular.

01.Tibial Intramedullary Nailing: samun dama da daidaitawa, ciwon gwiwa na gaba

Samun damar yin tiyata don ƙusa intramedullary na karaya na tibial yana da mahimmanci don shigar da ƙusa ta ciki ta wurin madaidaicin wurin shiga, don rage lalacewa ga sifofin gwiwa na ciki, da kuma cimma ingantacciyar gyaran ƙusa da shigar ƙusa mai dacewa.

Hanyoyi na yau da kullun don karaya mai tushe na tibial su ne hanyoyin infrapatellar na tsakiya ko hanyoyin parapatellar. Ko da yake ana nuna waɗannan hanyoyin don karyewar yanki na tsakiya, valgus na baya-bayan nan, nakasar baya, ko nakasar syndesmotic akai-akai a cikin karaya masu kusanci.

Babban abin da ke haifar da rashin daidaituwa a cikin ɓarna na tibial na kusa shine nakasar da aka haifar ta hanyar ja da ƙwanƙwasa quadriceps a lokacin ƙwanƙwasa gwiwa da rikici na inji tsakanin tip ƙusa da na baya na tibial cortex a lokacin shigar da shi. Har ila yau, patella yana hana shigarwar axial na ƙusa a cikin jirgin sama na sagittal (Fig. 1a, b). Sabili da haka, wata hanyar da aka saba shigar da ita ita ce ta hanyar tsaka-tsakin tsaka-tsakin tsaka-tsakin tsaka-tsakin tsaka-tsaki, wanda ya haifar da ƙananan ƙusa na tsakiya zuwa gefe (Figs. 1c da 2). Yayin da ƙusa ya shiga cikin canal na intramedullary zuwa karaya, ɓangaren kusa yana karkatar zuwa exostosis (Fig. 2). A ƙarshe, kwanciyar hankali na tsokoki na baya na baya yana taimakawa dan kadan zuwa ectropion (Fig. 3).

Hoto 1 a,b Yin amfani da tsarin infrapatellar na al'ada, patella yana hana shigarwar axial na ƙusa, wanda ya haifar da nakasar gama gari na gyare-gyaren apical sagittal alignment da ectropion coronal alignment.c Intramedullary ƙusa alignment an yi ta amfani da tsarin parapatellar.

Hoto 2 Kusanci wurin shiga ta hanyar tsaka-tsaki na tsaka-tsakin tsaka-tsaki yana kaiwa zuwa tsaka-tsaki kadan zuwa shigar da ƙusa na gefe. Yayin da ƙusa ya shiga magudanar ruwa mai nisa zuwa ga karaya (a), ɓangaren kusa yana karkatar da shi zuwa wuta (b)

Hoto 3 Huta tashin hankali na sashin tsoka na gaba (a) yana haifar da tsari na ectopic na dabara (b)

Ƙunar da tibia a cikin matsayi mai tsawo yana taimakawa wajen kauce wa matsalolin da ke hade da matsananciyar ƙwanƙwasa gwiwa.Gelbke, Jakma et al ya bayyana dabarar. a cikin 2010 kuma ya sami karɓuwa a cikin 'yan shekarun nan saboda ƙusa tibia a cikin matsayi na kusa da madaidaici yana sauƙaƙa magudi da kuma mayar da matsayi. Fluoroscopy ya zama sauƙi a fasaha don yin. An ba da rahoton lokacin fluoroscopy don ƙusa suprapatellar ya fi guntu fiye da na infrapatellar . Bugu da ƙari, kusurwar saka ƙusa (a cikin jirgin sama na sagittal) ya fi dacewa da tsayin daka na tibia tare da wannan hanya fiye da ƙusa infrapatellar; wannan yana hana karo na inji tsakanin tip ɗin ƙusa da na baya, don haka yana sauƙaƙe raguwa.

Ciwon gwiwa na baya bayan tiyata matsala ce mai dacewa. An ba da rahoton ciwon gwiwa na baya a cikin 50-70% na marasa lafiya tare da karaya, tare da 30% kawai na marasa lafiya suna fama da jin zafi bayan cirewar ƙarshen. An kiyasta samuwar tabo mai alaƙa da jijiyar patellar da kushin kitse na Hoffa zai zama tushen yuwuwar ciwon gwiwa bayan tiyata. Bugu da ƙari, tsarin suprapatellar yana guje wa ƙaddamar da al'ada na yanke reshe na reshe na patellar na jijiyar saphenous, wanda ke guje wa ƙwanƙwasa gwiwa na baya da kuma jin dadi (Hoto 4). Wucewa ƙusa ta hanyar ƙwanƙwasa quadriceps, ta haka barin jijiyar patellar ba ta da kyau, ya bayyana yana rage yawan ciwon gwiwa bayan tiyata.

Hoto 4 Dangantaka tsakanin jijiyar saphenous da samun dama ga ƙusa tibialis obliqua.

Sakamakon sakamako mai kyau na raunin da ya faru na kusa, alamun da ke cikin aikin asibiti an ƙaddamar da su zuwa duk raguwa.

Matsaloli masu yuwuwa tare da ƙusa intramedullary a cikin tsarin suprapatellar:

- Zai iya barin tarkace mai lalacewa a cikin haɗin gwiwa. Duk da haka, ƙwarewar asibiti tare da retrograde femoral nailing bai nuna wani mummunan tasiri na gajeren lokaci ko na dogon lokaci ba.

- Ta yaya ake cire dasa bayan karyewar ta warke? Kodayake yana da yuwuwar a zahiri don cire ƙusa na intramedullary ta hanyar tsarin suprapatellar, dabarar tana buƙatar kuma yawancin likitocin fiɗa sun fi son cire ƙusa na intramedullary ta hanyar infrapatellar.

02. Yaushe ya kamata a yi amfani da ƙusa intramedullary suprapatellar?

Amfani

- Matsayin gwiwa na Semi-Extended yana sauƙaƙe magudi da raguwa ta hanyar shakatawa da ƙarfin tsoka da riƙewa yayin shigar da ƙusa.

- Ƙarƙashin haɗari na rashin daidaituwa bayan aiki na kusa, kashi, da karaya mai nisa idan aka kwatanta da dabarun gargajiya

- Yin farce ya fi sauƙi a fasaha

- Yana yiwuwa a yi ƙusa a matsayin 'hanyar likitan fiɗa ɗaya'.

- Rage lokacin fluoroscopy

- Babu lahani ga tendon patellar da ƙarancin abin da ya faru na ciwon baya bayan farce

- Sauƙi don yin aiki a cikin tsarin ƙungiyoyi da yawa, kamar yadda yake tare da polytrauma.

Rashin amfani

- Haɗarin lalacewa ga guringuntsin gwiwa da sauran sifofin intra-articular

- Ƙara haɗarin kamuwa da ciwon gwiwa

- Cire dasawa na iya buƙatar wata hanya ta daban

Alamu

- Karin karaya na kusa da tibia (Nau'in AO 41A)

- Sauƙaƙen karaya na tibial diaphysis (nau'in AO 42A-C)

- Karayar tibial diaphysis (nau'in AO 42C)

- Extra-articular da sauƙi intra-articular distal tsawo karaya na distal tibia (nau'in AO 43A da C1)

- Gwiwa mai iyo

Contraindications

- Gustilo grade 3C bude karayar tibia saboda karuwar haɗarin kamuwa da cuta ta haɗin gwiwa, kodayake ba a ba da rahoton haɗarin kamuwa da haɗin gwiwa ba a cikin karaya.

- Tsanani mai laushi mai laushi, gurɓatawa ko kamuwa da cuta a cikin yankin suprapatellar

- Ipsilateral gwiwa prosthesis (ƙananan contraindication)

- Gwiwar gwiwa

- hawan jini na gwiwa> 20°

- Karyewar tibial plateau na Ipsilateral wanda ya shafi wurin shigar ƙusa sabani ne na dangi

- Tsirrai da ke toshe wurin shigar farce

- Ipsilateral patella karaya (dangi contraindications)

03. Hanyoyin tiyata

① Matsayin jiki da hangen nesa

Hoto 5 Mai haƙuri yana kwance a kan tebur mai radiyo wanda ke ba da izinin tsaga-ƙafa. An bar gunkin da ya karye yana rataye da yardar rai kuma ana sanya gungura ƙarƙashin haɗin gwiwa na gwiwa (a) don cimma 10-30° na jujjuyawar gwiwa. 

(b). An sanya C-arm a gefe guda. An saukar da ƙafar da ba ta dace ba 10-30 ° daga kwance don tabbatar da hoto mai kyau a matsayi na gefe.

②Nemo wurin shigar allura dama

Hoto 6 Wannan hanya tana da alamar alamar patella, tuberosity na tibial, da kuma na baya na tibial cortex. An yi katsewar fata mai tsayi cm 2 1-1.5 kusa da babban tushe na patella. An fallasa tendon quadriceps kuma an yi tsaka-tsakin tsaka-tsakin tsaka-tsaki a cikin hanyar filayen tendon. Ana buɗe hutun suprapatellar kuma yatsun likitan likitan sun shiga haɗin gwiwa daga ƙarƙashin patella don tantance sauƙin shiga. Ƙara ɗan ƙaran gaɓoɓin hannu na iya sauƙaƙe samun dama ga gwiwa. Shigar da na'urar retractor na Langenbeck don ɗan tsayin patella na iya haɓaka shiga. Idan sararin haɗin gwiwa yana da kunkuntar sosai kuma kayan aiki yana da wuyar gaske, za a iya ƙaddamar da ƙungiyar goyon baya na tsakiya ko na gefe kusa da shi domin ya rabu da patella a gefe ɗaya.

③Kare guringuntsi

Hoto 7 Kariya na guringuntsi na patellofemoral daga raunin da ya shafi aikin tiyata shine daya daga cikin manyan manufofi na aikin tiyata. Don haka, dole ne a yi amfani da hannayen riga masu kariya a lokacin shigar da kayan aiki da ƙusa.A Kayan aiki don samun damar shiga transarticular sun haɗa da hannayen hannu, na waje (laushi) da na ciki (karfe) hannayen kariya, trocar fil, da jagororin waya mara kyau. An haɗe allurar trocar tare da hannun riga mai karewa da abin sakawa.b Hannun hawa tare da ramukan samun iska na gefe. Ƙaƙwalwar da ke saman hannun abin da aka saka yana hana ɓarna cikin haɗari na taron riƙon

④ Saka jagorar jagora kuma daidaita matsayi

Hoto 8a An shigar da taro mai kulawa a ƙarƙashin patella ta hanyar haɗin gwiwa na patellofemoral zuwa wurin shigarwa da ake so akan tibia (Hoto 9). A mafi yawan lokuta, patella zai motsa dan kadan a tsakiya ko a gefe yayin shigar da kayan aiki. Tsagi a cikin haɗin gwiwa na patellofemoral yawanci yana jagorantar allurar trocar zuwa matsayi daidai ta atomatik.

Hoton 8b An tabbatar da matsayi a cikin duka jiragen sama ta amfani da fluoroscopy kuma an gyara inda ya cancanta. Sannan ana maye gurbin allurar trocar da madaidaicin jagorar jagora, mai jagora wanda ke ratsa tsakiyar rami na jagorar kuma wanda aka saka titinsa a cikin tibial metaphysis na kusa don tabbatar da matsayi daidai.

Hoto 8c Lokacin da jagorar jagorar ta kasance a cikin matsayi mafi kyau, ana iya amfani da jagorar jagora na biyu don yin gyare-gyare kaɗan a cikin mafi kyawun matsayi ta hanyar madaidaicin jagora, har zuwa iyakar 4.3 mm A madadin, yana iya zama sauƙi don farawa tare da jagorar kuma sanya shi ba tare da taimako ba a mafi kyawun wurin shigarwa. Na'urar shigarwa tare da wayan jagora ana zamewa akan wayan jagora.

⑤ Fadada medulla oblongata

Hoto 9a Bude rami na medullary daga madaidaicin wurin shigarwa mataki ne mai mahimmanci a cikin aikin tiyata. A cikin jirgin anteroposterior, wannan shine tsaka-tsakin tsaka-tsaki na tibial spur na gefe. A cikin jirgin sama na gefe, madaidaicin shigarwa yana samuwa a tsaka-tsakin tsaka-tsakin tsaka-tsakin da kuma na baya.

Hoto 9b Matsayi daidai na jagorar jagora yana cikin layi tare da tibial axis a cikin jirgin sama na anteroposterior kuma yana kusa da layi daya da cortex na baya kamar yadda zai yiwu a cikin tsinkaya na gefe. Wire ɗin jagora yana ƙoƙarin motsawa a baya.

Hoto na 9c A lokuta da ba za a iya saka fil ko ƙusa daidai ba, toshe ƙusa ko fil yana taimakawa wajen jagorantar ƙusa zuwa daidai matsayi. 

Ana amfani da kusoshi masu toshewa a cikin faɗin yanki na metaphyseal lokacin da jagorar ko ƙusa ba za a iya daidaita su daidai da madaidaicin kusurwoyi na kashi ba ko lokacin da ɓarna a cikin jirgin ɗaya ko duka biyun ya kasance yayin saka ƙusa.

Hoto 10 A wannan mataki, ana ba da shawarar cewa za a adana taro mai kulawa zuwa ga mata ta hanyar amfani da waya mai jagora na 3.2 mm. Wannan yana hana taron fita daga tibia.

Hoto 11 An sanya ramin rami mai zurfin mm 12.0 ta hannun hannun kariya na ciki kuma ƙasa ta hanyar jagorar zuwa kashi. Ana buɗe tashar medullary ta hanyar hakowa zuwa zurfin 8-10 cm kuma an saka wariyar jagorar da ta ƙare a cikin tibia mai kusanci.

⑥ Rage karaya

Hoto 12a A wannan mataki, mun sake saita karaya.

Hoto na 12b Dangane da wurin da aka samu karaya da yanayin halittarsa, ana iya amfani da kayan aikin rage iri-iri kamar faifan bidiyo, retractors, ƙananan faranti, da kuma toshe screws don cimma daidaitattun daidaito. A cikin raguwar karyewar tibial na kusa, wani lokacin ma tare da taimakon ƙarin dasawa, kafin buɗe tashar medullary ta hakowa. An ci gaba da reaming sanda a nisa kuma an saka shi cikin tsakiyar tibial metaphysis mai nisa. Bayan sakewa, an ƙayyade tsayi da diamita na ƙusa. Idan ya cancanta, haɓaka canal na tibial zuwa diamita da ake so ta hanyar haɓaka cikin haɓaka 0.5 mm. Buɗewa a hannun hannun riga mai karewa yana ba da damar yin ruwa da tsotsa tarkace daga haɗin gwiwa yayin reaming. Idan za ta yiwu, ana ba da shawarar cewa a yi amfani da ƙusa mai ƙarancin diamita na 10 mm. 5.0mm Locking Bolt na irin wannan nau'in ƙusa ya fi juriya ga gazawa fiye da 4.0mm Locking Bolt da ake amfani da shi don ƙuso mafi kyau. Tsawon kusoshi na intramedullary yawanci ana ƙaddara tare da mai sarrafa fluoroscopic.

⑦ Saka intramedullary ƙusa

Hoto 13a Shigar ƙusa ta sandar reaming ƙarƙashin fluoroscopy. Lura cewa hannun shigar da ƙusa na suprapatellar ya fi tsayi fiye da na ƙusa infrapatellar saboda nisa daga ƙaddamarwar fata zuwa wurin shigar ƙusa tibial shima ya fi tsayi.

Hoto 13b Lura cewa lanƙwasa (Herzog curve) a kusa da ƙarshen ƙusa na intramedullary ba za a iya saka shi ta hannun rigar ƙarfe na ciki ba. Don haka, dole ne a cire hannun rigar kariya na ciki daga majalissar riƙon kafin a saka ƙusa (b; duba sashin 'Kurakurai, Hatsari da Matsaloli'). Bincika matsayi na ƙarshe na ƙusa intramedullary a cikin gaba-baya da ra'ayi na gefe. Cire sandar reaming. Idan ana buƙatar canza ƙusa, bar sandar reaming a wurin kuma saka sabon ƙusa a cikin sandar. Alamar 5 mm akan abin da aka saka yana nuna zurfin shigar da abin da aka sanya a cikin tibia mai kusanci (Fig. 14). (Hoto na 14)

⑧ Kulle nesa da kusanci

Hoto 14a Matsakaicin kullewa na kusa da nesa sun dogara da takamaiman halaye na karaya. Za'a iya cika makullin kusa da hannu mai niyya. An cika kulle nesa da hannu kyauta ko ta hanyar amfani da jagorar rawar rediyo. Zabi, za a iya amfani da murfin ƙarewa, wanda ke hana ƙashi girma zuwa ƙarshen ƙusa na intramedullary kuma yana sauƙaƙe cirewa daga baya. Musamman ma, ƙusoshin da aka saka a kan sun fi sauƙi don cirewa lokacin da aka yi amfani da iyakar iyakar tsayin da ya dace. Ana auna tsawon iyakar da ake so ta hanyar saka alama a kan hannu ko ta hanyar saka waya mai jagora ta hannun hannu.

Hoto 14b Tip na jagorar waya yana nuna matsakaicin matsayi na ƙusa intramedullary. Ana buƙatar cire dunƙule da ke haɗa hannu da ƙusa don saka hular ƙarshen. Ƙarshen hular yana wucewa ta cikin ganga na hannun abin sakawa. Hannun shigar yana nan a wurin. Wannan yana daidaita murfin ƙarshen tare da saman ƙusa na intramedullary kuma yana hana shi daga rasa a cikin gwiwa. Shigar da wayan jagora ta cikin murfin ƙarshen ganga zuwa ƙarshen ƙusa kuma yana taimakawa jagorar hular ƙarshen ƙusa zuwa matsayin da ya dace a kusa da ƙarshen ƙusa na intramedullary. A ƙarshen aikin, ya kamata a wanke ruwan saline mara kyau don wanke sauran tarkace.

04. Tsanaki

Kariya don Ayyukan Tiyata

- A lokuta na ciwon osteoarthritis da aka rigaya, ƙuntataccen motsi na patellar na iya hana haɗin haɗin gwiwa. Ƙaddamar da yanki na kusa na tsaka-tsaki ko ƙungiyar tallafi ta gefe daga gefen tsakiya yana sauƙaƙe shigar da fil ɗin trocar.

- Prosthesis na gwiwa na ipsilateral ba taƙaddama ce mai tsauri ga maƙallan suprapatellar ba. Lura, duk da haka, cewa ƙila ba zai yiwu a sami damar zuwa wurin farawa da aka saba na tsarin ƙusa tibial na kusa ba.

- A cikin karaya tare da tsawo na articular, ana iya shigar da ƙarin sukurori don hana ɓarna ɓarna. Ana ba da shawarar cewa a sanya waɗannan sukurori kafin a saka ƙusa don guje wa sake komawa na biyu na karaya.

La'akarin Karɓar Tibia Kusa

Karyawar tibial na kusa sune mafi wahala ga ƙusa tibial zuwa ƙusa kuma suna buƙatar madaidaicin wuraren shiga (kamar yadda aka bayyana a sama). Ya kamata a rage waɗannan karaya kafin ƙusa don tinkarar duk wani ƙarfi mai nakasa da haɓaka nasara. A wasu lokuta, daidaitaccen matsayi da abin ya shafa a cikin wani wuri mai tsayi da samun madaidaicin wurin shiga da kuma sanya ƙusa tare da tashar medullary a cikin coronal da gatari na sagittal zai haifar da daidaitaccen daidaitawar tibia bayan ƙusa.

Duk da haka, a mafi yawan lokuta, ana buƙatar wasu motsin ragewa don samun da kuma kula da sake mayar da waɗannan karaya mai gamsarwa. Idan layin karaya mai sauƙi ne kuma mai kusurwa, mai sauƙi mai nunin sake saitin ƙusoshi ko ƙuƙumma, wanda aka sanya shi gaba ɗaya, ana iya amfani da shi don samu da kiyaye sake saiti yayin ƙusa. Idan matsi bai isa ba ko kuma jirgin da ya karye bai ba da kansa ba don murƙushewa, pollen ko toshe skru na iya taimakawa wajen hana ƙaura da rashin daidaituwa (Hoto 15). Ana sanya waɗannan ƙusoshin a baya zuwa matsayi na ƙusa da ake so a kan ra'ayi na gefe da kuma gefe zuwa matsayi na ƙusa da ake so a kan hangen gaba-baya. Matsayin da ya dace na waɗannan sukurori don sake saiti mai kyau na iya zama ƙalubale.

Hoto 15 Makulle sukulan sanya a waje na hanyar ƙusa da ake so a gaba da ra'ayi na baya (a) da kuma bayan hanyar ƙusa da ake so a cikin ra'ayi na gefe (b) yana magance sojojin nakasa.

Wani fasaha mai tasiri mai mahimmanci shine gyaran wucin gadi na raguwa a cikin matsayi na jiki (Fig. 16). Yawanci ƙaramin farantin tubular gutsure tare da kusoshi na kulle cortical guda biyu ko uku zai riƙe karaya da aka rage yayin shirye-shiryen tushen canal da saka ƙusa. Farantin zai sarrafa duka ƙaura. Ya kamata a bar farantin a wuri muddin babu tsayayyen rata don hana asarar raguwa wanda yawanci ke faruwa bayan cire farantin. Wannan farantin tare da dunƙule cortical guda ɗaya ba ta da ƙarfi kuma ba zai shafi kwanciyar hankali na ƙusa ba. Za a iya amfani da dabarar sake saitin farantin don duka buɗaɗɗe da rufaffiyar karaya.

Hoto 16 Za'a iya samun ƙaramin farantin kulle tare da dunƙule cortical guda ɗaya kuma a kiyaye shi a cikin sake fasalin jiki. A mafi yawan lokuta, ya kamata a bar farantin a wuri bayan ƙusa. Nakasar valgus ta farko na karayar tibial na kusa. b Ana sanya ƙaramin farantin karaya tare da dunƙule cortical guda ɗaya a tsaka-tsaki don samun da kula da sake fasalin karaya yayin ƙusa. c Ba a cire farantin bayan ƙusa ba saboda yana ba da ƙarin kwanciyar hankali

Kuskure, Hatsari da Matsaloli

- Maɓalli na ciki na Kariyar Sleeve na iya haifar da lalacewa ga guringuntsi da tsarin gwiwa na ciki (Hoto 17). Dole ne a sake shigar da hannun rigar kariyar gabaɗaya.

- Dan karkatar da Hannun Kariya na iya kara tsananta hako kai na reamer. Fluoroscopy yana taimakawa wajen gano matsalar. Sake daidaita hannun rigar kariya zai magance matsalar (Fig. 18)

- Kulle Kulle: Tushen na iya zama makale a cikin hannun karfe a lanƙwasa kusa (Herzog curve). Don shigar da ƙusa na ƙarshe, ana buƙatar cire bututun ƙarfe, barin hannun rigar filastik na waje kawai. Lokacin da ƙusa ya makale, yana buƙatar sake cire shi gaba ɗaya kuma a sake shigar da shi bayan cire ƙwayar ƙarfe ta cikin cannula na filastik kawai.

Hoto 17 Janye hannun rigar kariya ba tare da kallon fluoroscopic ba na iya haifar da rauni a gwiwa

Hoto na 18 Tsayawa ko karkatar da akwati na bazata na iya tsoma baki tare da cire reamer, kamar yadda kan reamer na iya matsewa. b Binciken fluoroscopic tare da gyara jeri yana ba da damar cire kan reamer. c Ana iya cire shugaban reamer idan ba a wurinsa. d Za a iya cire shugaban reamer idan ba a wurinsa.

Nassoshi

Hessmann MH, Buhl M, Finkemeier C, Khoury A, Mosheiff R, Blauth M. Suprapatellar nailing na karaya na tibia. Oper Orthop Traumatol. Oktoba 2020; 32 (5): 440-454.