Tibial Intramedullary Nail Fixation Technique

ʻO ka hoʻoponopono nail Intramedullary ka mālama ʻana i ke koho no nā haʻihaʻi kumu tibial paʻa ʻole a hoʻoneʻe ʻia i nā pākeke. ʻO ka pahuhopu o ka lāʻau lapaʻau e hoʻihoʻi i ka lōʻihi, alignment a me ka hoʻololi ʻana o ka tibia a e hoʻokō i ka ho'ōla haʻihaʻi. ʻO nā pōmaikaʻi o ka nailing intramedullary he hōʻeha liʻiliʻi liʻiliʻi a mālama pono i ke kahe koko i ka haʻihaʻi. Eia kekahi, ʻo ke kui intramedullary o ka tibia e hāʻawi i ka paʻa biomechanical fracture kūpono a hana ma ke ʻano he mea hoʻoili ukana e ʻae ai i ka hoʻoneʻe mua ʻana i ka postoperative. ʻO nā holomua i ka hoʻolālā nail intramedullary a me nā ʻenehana hōʻemi i hoʻonui i nā hōʻailona no ka hoʻoponopono nail intramedullary e hoʻokomo i ka tibia proximal a me nā haʻihaʻi waena waena.

A hiki i kēia lā, ua lilo ka hoʻopaʻa ʻana i ka hoʻopaʻa ʻana o ka nail intramedullary i kahi hana maʻamau no nā mea lapaʻau orthopedic trauma. ʻOiai ke kaulana o ka hoʻoponopono nail intramedullary no ka haʻihaʻi ʻana o ke kumu tibial i hoʻoneʻe ʻia, paʻakikī ia a he nui nā pilikia. Ke hoʻomau nei ka ulu ʻana o nā ʻano hana ʻoki. ʻO ke kumu o kēia ʻatikala ʻo ia ka wehewehe ʻana i nā manaʻo o kēia manawa i ka hoʻoponopono nail intramedullary o nā haʻihaʻi kumu tibial a me ka hōʻuluʻulu ʻana i nā holomua hou i ke kula.

一. ʻO ka loiloi mua a me ka nānā ʻana

I nā poʻe maʻi liʻiliʻi, ʻo ka tibial stem fracture ka hopena o nā hōʻeha kiʻekiʻe, a pono e loiloi ʻia nā mea maʻi no ka trauma pili e like me nā alakaʻi alakaʻi Advanced Trauma Life Support (ATLS). E loiloi i nā ʻeha a puni ka ʻili a me nā ʻiʻo palupalu e like me ka ʻeha o ka ʻili, ka ʻeha o ka ʻili, ke kuni, ka ecchymosis, a i ʻole ka piʻi ʻana o ka ʻili; e wehewehe inā ua hāmama ka haʻihaʻi, a inā pēlā e mālama me ka tetanus a me nā lāʻau antibiotic; a e hana i kahi hoʻokolokolo neurovascular holoʻokoʻa a kākau i nā mea i luna. E loiloi i ka loaʻa ʻana o ka osteofascial compartment syndrome a hana i kahi ʻano o nā hoʻokolohua lapaʻau i kēia mau maʻi.

Ua hōʻike ʻia nā haʻawina hou e hiki i ka 11.5% ke kiʻekiʻe o ka maʻi o ka osteofascial compartment syndrome ma hope o ka haʻi ʻana o ka tibial tuberosity. ʻO ka mea nui, hiki i nā hui maʻi ʻōpio ke hoʻomohala i ka maʻi osteofascial compartment. Pono e hoʻokumu ʻia ka hōʻailona o ka osteofascial compartment syndrome ma luna o nā ʻike lapaʻau, me ka ʻeha nui, nā loli neurovascular, ka pehu ʻana o ka myofascial compartment, a me ka hoʻonui ʻana i ka ʻeha mai ka hoʻonui ʻana i ka wāwae passive. No laila, noho mau ka osteofascial compartment syndrome i kahi maʻi maʻi a he mea nui ka palapala kikoʻī o ka hoʻokolohua lapaʻau. Hiki ke ana ʻia ke kaomi ʻana i loko o ka ʻāpana myofascial ma o ka nila kaomi (Figure 1) ma ke ʻano he ʻano hoʻokolohua hoʻohui i ka hoʻokolohua kūikawā.

Kiʻi 1. ʻO ke ana o ke kaomi i loko o ka interosseous septum ma o ka nila kaomi

No ka loaʻa ʻana o ka ʻikepili hilinaʻi, pono e ana ʻia nā kaomi intrafascial ma nā ʻāpana myofascial ʻehā a ma nā wahi like ʻole i loko o kēlā me kēia keʻena myofascial. Hōʻike nā haʻawina i loko o ka puke moʻolelo e hōʻike ana ka ʻokoʻa puʻe ma lalo o 30 mmHg (ke kaomi diastolic me ke kaomi ʻana o ka fascial compartment) i kahi maʻi ʻāpana fascial. Hoʻemi pinepine ʻia ke kaomi diastolic i ka wā o ke kaʻa ʻana, a pono e noʻonoʻo ʻia ke kaomi diastolic preoperative i ka helu ʻana i ke kaomi ʻokoʻa.

Ua hōʻike ʻia nā haʻawina hou i ka nānā ʻana i ke kaomi intrafascial he mea pono kūpono no ka ʻike ʻana i ka maʻi o ka maʻi o ka fascial compartment, me ka sensitivity o 94% a me kahi kikoʻī o 98%. Eia nō naʻe, ma muli o nā hopena pōʻino o ka compartment syndrome, pono e hoʻokumu ʻia ka hōʻailona o ka compartment syndrome ma luna o nā ʻike lapaʻau, a pono e hoʻohana ʻia nā ana kaomi interosseous i nā kūlana kūikawā, e like me ka wā i hōʻeha ʻia ai ka mea maʻi a i ʻole ka maopopo ʻole o nā helu ʻikepili.

Pono e hoʻokomo i ka loiloi kiʻi i nā orthopantomograms maʻamau a me nā hiʻohiʻona ʻaoʻao o ka tibia i ʻeha a me nā radiographs o ke kuli a me nā hui kuʻekuʻe e pili ana, i loiloi hou ʻia me ka hoʻohana ʻana i ka computed tomography (CT). Pēlā nō, pono paha kahi CT scan o ka kuʻekuʻe wāwae e ʻike i nā laina haʻihaʻi e hoʻonui ana i ka pāpū tibial a me nā ʻeha kuʻekuʻe wāwae ʻole.

二. ʻO nā pilikia lapaʻau

Ua hōʻike ʻia kahi haʻihaʻi kiʻekiʻe o ka hapakolu waena o ka tibia me nā wāwae wāwae. Me ka hoʻohana ʻana i ka CT scan maʻamau, 43% o nā haʻihaʻi o ka waena a me ka hapakolu o lalo o ka tibia i hele pū ʻia me nā haʻi kuʻekuʻe wāwae, ʻo ka hapa nui o ia mau mea e pono ai ka mālama ʻana. ʻO ke ʻano o ka haʻihaʻi maʻamau, ʻo ia ka haʻihaʻi spiral o ka hapakolu waena haʻahaʻa o ka tibia distal e pili ana me kahi haʻi kuʻekuʻe wāwae liʻiliʻi a i ʻole i hoʻoneʻe ʻia (Figure 2). Ma muli o ka liʻiliʻi ʻana o ka haʻihaʻi wāwae e pili ana, hiki ke ʻike ʻia he 45% o nā ʻeha ma nā lekiō kuʻekuʻe wāwae. No laila, pono e hoʻoikaika nuiʻia ka CT scans o ka kuʻekuʻe wāwae ke loaʻa kahi haʻihaʻi o ka tibia waena (Fig. 3).

Kiʻi 2.AF ʻO ka haʻihaʻi wili o ka hapakolu waena haʻahaʻa o ka tibia ʻākau (A, B) Hōʻike ʻia nā radiographs preoperative o ka kuʻekuʻe wāwae (C). Hōʻike ʻo Intraoperative C-arm fluoroscopy i kahi haʻi ʻole o ka kuʻekuʻe wāwae hope (D) Hōʻike nā radiographs postoperative ma hope o ka hoʻoponopono ʻana (EF) i ka hoʻōla maikaʻi ʻana o ka tibial a me nā wāwae wāwae.

Kiʻi 3. AF ʻO ka haʻihaʻi o ka waena a me ka hapakolu o lalo o ka tibia hema (AB) radiograph preoperative; (CD) preoperative CT scans e hōʻike ana i ka nondisplaced posterior malleolar fracture; (EF) e hōʻike ana i ka hoʻōla maikaʻi ʻole o ka tibia a me ka haʻihaʻi malleolar

三. Nā ʻano hana ʻokiʻoki

01. Lae Komo Nila Tibial

He kuleana koʻikoʻi ka hoʻokumu ʻana i kahi helu komo pololei a ua hāʻawi nā haʻawina he nui i ka palapala i ka ʻike koʻikoʻi e pili ana i ka wahi anatomical o ka wahi komo kūpono no ka nailing intramedullary o nā tibial fractures. Ua hōʻike kēia mau haʻawina e loaʻa ana ka pine pine kūpono ma ka ʻaoʻao mua o ka pāpū tibial a me ka medial wale i ka lateral tibial spur. Ua hōʻike pū ʻia kekahi wahi palekana me ka laulā o 22.9 mm ± 8.9 mm, ʻaʻole ia e hōʻino i nā hale hui pili. ʻO ka mea maʻamau, ua hoʻokumu ʻia ka wahi hoʻomaka no ka hoʻopaʻa ʻana o ka nail intramedullary o nā ʻōpala tibial stem ma o ka infrapatellar approach, a i ʻole ma ka hoʻokaʻawale ʻana i ka tendon patellar (transpatellar approach) a i ʻole ka wehe ʻana i kahi ʻāpana o ka patellar tendon stop (paratendinous approach).

ʻO ka semi-extension intramedullary nailing ua hoihoi nui i ka nānā ʻana i nā palapala orthopedic hou, a ʻo Tornetta lāua ʻo Collins e manaʻo e hoʻohana i kahi ala parapatellar medial no ka hoʻopaʻa ʻana i loko o ka nail i ke kūlana semi-extension e pale aku i ka hoʻokuʻi ʻana o ka apex o ka nail intramedullary i loko o ka tibial cortex anterior. ʻōlelo ʻia ke kūlana. Hoʻohana ʻia ka hoʻohana ʻana i kahi suprapatellar no ka tibial intramedullary nailing a me ka hoʻokomo ʻana o ka nail intramedullary ma o ka hui patellofemoral i ke kūlana semi-extended.

Hana ʻia ke kaʻina hana me ke kuli i hoʻololi ʻia ma kahi o 15-20 degere, a ua hana ʻia kahi ʻoki longitudinal ma kahi o 3 kenimika ma kahi o hoʻokahi a ʻelua mau manamana lima ma luna o ka patella. Hoʻokaʻawale ʻia ka tendon quadriceps ma kahi ʻano longitudinal a hana ʻia ka ʻoki ʻoki ʻana i loko o ka hui patellofemoral. Hoʻokomo ʻia kahi kumu blunt ma o ka hui patellofemoral e hana i kahi helu komo ma ka hui o ka cortex tibial anterior proximal a me ka ʻili articular (Figure 4).

Kiʻi 4. ab Nā kiʻi paʻi kiʻi o (a) ka hoʻokaʻawale ʻana i ka tendon quadriceps a hoʻokomo i ka trocar ma o ka hui patellofemoral a hiki i ka helu komo tibial; (b) nānā ʻaoʻao intraoperative o ka wahi komo

Hoʻohana ʻia ka bit drill 3.2 mm no ka hoʻoholo ʻana i ke kiko o ka nila hoʻomaka ma lalo o ke alakaʻi lima C. Hāʻawi ʻia kahi kumu puka no ka hoʻoponopono ʻana i nā wahi komo a puka. Hoʻokomo ʻia nā kaʻina hana ʻoki i koe e like me ka reaming a me ka hoʻokomo ʻana i nā kui tibial ma o ke kumu.

NĀ PONO: ʻO ke kūlana wāwae semi-extended hiki ke kōkua i ka hoʻonohonoho hou ʻana i ka haʻihaʻi, ʻoi aku hoʻi i nā haʻihaʻi me kahi hapakolu kokoke o ka tibia a me ke kihi i mua. , Hiki i ke kūlana semi-extended ke hoʻopau i ka haʻalulu ma ka ʻiʻo quadriceps a kōkua i ka hoʻonohonoho hou ʻana i ka haʻihaʻi. , Hiki i ke kūlana semi-extended suprapatellar approach ke lilo i mea'ē aʻe i keʻano infrapatellar kuʻuna (Figure 5).

Kiʻi 5. ʻO ke kiʻi intraoperative e hōʻike ana i ka ʻeha o ka ʻiʻo palupalu ma ka ʻāpana infrapatellar ma ke ʻano he hōʻailona no ka hoʻokokoke suprapatellar ma kahi kūlana semi-extended.

Ua hōʻike nā haʻawina i ka hoʻokokoke suprapatellar i ka tibial intramedullary nailing i ke kūlana semi-extended he ʻano hana palekana a maikaʻi. Pono nā hoʻokolohua lapaʻau e hiki mai ana e noiʻi hou i nā pono a me nā hemahema o ka suprapatellar approach intramedullary nailing a no ka loiloi i nā hopena lōʻihi e pili ana i kēia ʻano hana.

02. Hoʻoponopono hou i ka ʻenehana

ʻO ke kau ʻana o kahi kui tibial intramedullary wale nō ʻaʻole ia e hoʻemi i ka haʻihaʻi kūpono; Pono e mālama ʻia ka emi ʻana o ka haʻihaʻi kūpono i ke kaʻina hana reaming a me ka hoʻokomo ʻana i nā kui intramedullary. ʻAʻole hiki i ka hoʻohana ʻana i ka traction manual wale nō ke hoʻokō i ka hōʻemi anatomic o ka haʻi ʻana iā ia iho. E wehewehe ana kēia ʻatikala i nā ʻano hana hoʻohaʻahaʻa i pani ʻia, liʻiliʻi liʻiliʻi, a me ka wehe ʻana.

- Nā ʻōlelo aʻoaʻo ʻenehana hoʻoponopono hou

Hiki ke hoʻokō ʻia nā hana hoʻoemi pani ʻia me kahi mea hana hoʻohaʻahaʻa e like me ka F-fracture reducer, kahi mea hoʻoemi radiographically transmissible hoʻoemi F i hoʻoponopono ʻia no nā kihi hoʻohuli a me ka unuhi medial/lateral (Fig. 6).

Fig. 6. ʻO ka mea hōʻemi haʻihaʻi F-like i ʻōlelo ʻia ma ke ʻoki ʻana

Eia nō naʻe, hiki i ka mea hana ke kau i ke koʻikoʻi nui i nā ʻiʻo palupalu, a pono e pale ʻia ka hoʻohana lōʻihi ʻana i kēia mea hoʻoponopono hou. Hiki ke hoʻokomo ʻia nā forceps hoʻohaʻahaʻa ma ke ʻano maʻamau, e like me ke ʻano o ka haʻi ʻili a me ka oblique. Hiki ke hoʻohana ʻia kēia mau mea hana ma kahi ʻano maʻalahi me nā ʻoki liʻiliʻi (Figure 7).

Kiʻi 7. ʻO ka hoʻopaʻa ʻana i ke kino e hoʻihoʻi hou i kahi haki tibial

Pono e koho ʻia ke ʻano o ka hoʻopaʻa ʻana a me ka wahi o ka ʻoki ʻoki ʻana ma muli o kahi hoʻolālā e hōʻemi i ka pōʻino lōʻihi i nā ʻiʻo palupalu mai ka hoʻokomo ʻana (Figure 8).

Fig. 8. Hoʻonohonoho hou ʻia nā kīʻaha e hoʻihoʻi hou i ka haʻihaʻi tibial

ʻO Retractors kekahi o nā mea hana hoʻoponopono maʻamau i hoʻohana ʻia e hoʻihoʻi i ka lōʻihi i ka tibia. Hoʻokomo pinepine ʻia lākou ma waena a ma waho o kahi e pono ai ke kau ʻana i ke kui intramedullary. Hiki ke hoʻokomo ʻia nā pine traction proximal e hoʻohālike i ke kūlana pani pani kokoke, e hiki ai ke hōʻemi maʻalahi i ka haʻi ʻana i ka wā i komo ai ke kui intramedullary.

I kekahi mau hihia, ʻaʻole lawa nā ʻenehana hōʻemi i pani ʻia a me ka liʻiliʻi loa no ka loaʻa ʻana o ka hōʻemi anatomic. Ma ia mau hihia, pono e noʻonoʻo ʻia nā ʻenehana hōʻemi insional me ka mālama pono ʻana i nā ʻiʻo palupalu a puni. ʻO nā pōʻino kūpono ʻole o nā ʻenehana hōʻemi hāmama e pili ana i ka ʻeha ʻokiʻoki ʻē aʻe, hiki ke hoʻonui i ka pilikia o ka maʻi ma kahi o ke kaʻina hana. Eia kekahi, ʻo ka wehe ʻana i ke koko i ka wahi haʻihaʻi hiki ke hoʻonui i ka pilikia o ka haʻi ʻole o ka postoperative.

-ʻIke loea no ka ʻoki a me ka hoʻonohonoho hou ʻana

ʻAʻole ʻae nā hana hoʻohaʻahaʻa hoʻohaʻahaʻa i ka ʻokiʻoki wale ʻana i hoʻonoho ʻia ma ke kūlana kūpono, akā, ʻo ka hoʻohana ʻana i nā splints liʻiliʻi a liʻiliʻi paha ma ka wahi haʻi e mālama ai i ka hōʻemi haʻi ʻana i ka wā o nā kaʻina hana nailing intramedullary.

Hoʻopaʻa ʻia nā papa i nā ʻāpana haʻihaʻi kokoke a me ka distal me ka hoʻohana ʻana i nā wili monocortical. Mālama ʻia ka splint i ke kaʻina hana o ka reaming a me ke kau ʻana o ke kui intramedullary i ka tibia. Ma hope o ka hoʻokomoʻana i ke kui intramedullary, ua weheʻia ka pā a waihoʻia paha ma kahi e hoʻonui ai i ka paʻa o ka hale paʻa (Figure 9). Ma ka waiho ʻana i ka pā, pono e hoʻololi ʻia ka wili cortical hoʻokahi me ka wili cortical pālua. Pono e noʻonoʻo ʻia no ka hoʻohana ʻana i nā hihia i koho ʻia kahi e koi ai ke kumu tibial i kahi ʻoki ākea e hiki ai ke hōʻemi i ka haʻihaʻi ʻae ʻia.

Kiʻi 9. Wehe tibia haʻihaʻi me ka nui comminution a me ka iwi kīnā, hoʻokahi cortical hoʻopaʻa 'ana me ka liʻiliʻi maʻi ma ka haʻi hope o ka haʻihaʻi ma hope o ka emi a me ka wehe 'ana o ka splint ma hope o intramedullary nail fixation.

ʻO ke kumu o ka nail ālai ʻia e hōʻemi i ka lua medullary ma ka ʻāpana metaphyseal. Hoʻokomo ʻia nā kui pale i loko o ka ʻāpana articular pōkole a ma ka ʻaoʻao concave o ka deformity ma mua o ke kau ʻana i nā kui intramedullary. ʻO kahi laʻana, ʻo ka deformity maʻamau o kahi haʻihaʻi o ka hapakolu kokoke o ka tibia i hōʻike ʻia e ka valgus a me ka angulation i mua. No ka hoʻoponopono ʻana i ka deformity valgus, hiki ke hoʻokomo ʻia kahi wili laka ma ka ʻaoʻao ʻaoʻao o ka ʻāpana haʻihaʻi kokoke (ʻo ia hoʻi, ka ʻaoʻao concave o ka deformity) ma kahi ʻaoʻao anteroposterior. E alakaʻi ʻia ka nail intramedullary mai ka ʻaoʻao medial, e pale ai i ka valgus. Pēlā nō, hiki ke hoʻokō ʻia ka hoʻohaʻahaʻa angulation ma ke kau ʻana i ka ʻūlū laka ma ka ʻaoʻao o ka ʻaoʻao hope o ka poloka proximal (ʻo ia hoʻi, ka ʻaoʻao concave o ka deformity) (Figure 10).

Kiʻi 10. kōkua ʻia ka hoʻihoʻi hou ʻana i ka haʻihaʻi o ka tibial ma ke kau ʻana i nā kui pale

-Medullary hoʻonui

Ma hope o ka pau ʻana o ka hoʻonohonoho hou ʻana o ka haʻi, koho ʻia ka medullary reaming e hoʻomākaukau i ka iwi no ka hoʻokomo ʻana i ke kui intramedullary. Hoʻokomo ʻia ka uea alakaʻi i hoʻopau ʻia i ka pōleʻa i loko o ka lua o ka momona o ka tibial a ma o ka wahi haʻihaʻi, a ke kau ʻia ka reaming drill ma luna o ke alakaʻi i hoʻopau ʻia. Ua hoʻokūpaʻa ʻia ke kūlana o ke alakaʻi i hoʻopau ʻia i ka pōleʻa ma lalo o ka C-arm fluoroscopy ma ke kiʻekiʻe o ka hui kuʻekuʻe wāwae, a ua kau pono ke alakaʻi i nā hiʻohiʻona anteroposterior a me ka ʻaoʻao (Figure 11).

Hōʻike ka Helu 11. i ke kūlana o ke kaula alakaʻi i loko o ka lua medullary ma ka C-arm fluoroscopy ma ke alo a me ke kūlana ʻaoʻao.

Ua hoʻopaʻapaʻa ka pilikia o ka medulla i hoʻonui ʻia me ka hoʻonui ʻole ʻia. Ke manaʻoʻiʻo nei mākou ʻo ka hapa nui o nā kauka lapaʻau ma ʻAmelika ʻĀkau e makemake i ka hoʻonui ʻia o ka medullary intramedullary nailing o ka tibia i ka hoʻonui ʻole. Eia naʻe, hiki ke hoʻohana ʻia nā kui intramedullary hoʻonui a hoʻonui ʻole ʻia e like me nā ʻenehana maʻamau, a hiki ke loaʻa nā hopena maikaʻi me nā ʻano ʻelua.

-Ka hoʻokomo ʻana i ka wili

Hoʻohana ʻia ka hoʻohana ʻana i nā wili i loko o nā ʻōpala tibial stem e pale aku i ka pōkole a me ka malrotation, e hoʻonui i nā hōʻailona no ka nailing intramedullary o ka tibia i ka ʻoi aku ka proximal a me ka distal stem fractures e pili ana i ka metaphysis. I nā haʻihaʻi e pili ana i ka ʻāina metaphyseal, ua lilo nā wili i mea nui i ka mālama ʻana i ka alignment axial.

ʻEkolu mau wiliwili pili kokoke i hoʻomaikaʻi maikaʻi loa i ka paʻa, a ʻo nā wili hoʻopaʻa i hoʻopaʻa ʻia i ke kihi hiki ke hāʻawi i ka paʻa ʻoi aku ka paʻa ma mua o nā wili hoʻopaʻa maʻamau, hiki ke loaʻa ka paʻa paʻa like me ka helu liʻiliʻi o nā wili pili. ʻO ka ʻikepili lapaʻau e pili ana i ka helu a me ka hoʻonohonoho ʻana o nā wili e pono ai no ka hoʻoponopono ʻana i loko o ka tibia i kaupalena ʻia.

Hoʻokomo pinepine ʻia ka hoʻokomo ʻana i nā ʻūlū pili kokoke me ka hoʻohana ʻana i kahi ākea i hoʻopili ʻia i ka spike nail intramedullary. Hoʻokomo lima lima ʻole ʻia nā wiliwili ʻokoʻa ma lalo o ke alakaʻi fluoroscopic. Manaʻo ʻia ka hoʻohana ʻana i kahi ʻōnaehana alakaʻi kōkua kamepiula electromagnetic no ka hoʻokomo ʻana i nā screws interlocking tibial distal (Figure 12). Hāʻawi kēia ʻenehana i ka hoʻokomo ʻana i ka radiation-free hoʻokomo ʻana i nā wili hoʻopili mamao a ua hōʻike ʻia he ala kūpono a pololei.

Kiʻi 12.AB Laka ʻana i nā wili ma o ka C-lima hiʻohiʻona; ʻO nā wili wili CD ma o ka laka ʻana i kōkua ʻia e ka lolouila electromagnetic

ʻO ka hoʻokomo ʻana i nā wili liʻiliʻi kokoke a me ka mamao he kaʻina kaʻina hana palekana a pono e hoʻokomo ʻia nā wili hoʻopili i kahi ʻano kūpono a me ka palupalu.

Ua hōʻike ʻia nā haʻawina Anatomic aia nō ka pilikia o ka maʻi maʻi maʻi maʻi peroneal i ka wā e hoʻokomo ai i ka medial proximal a i nā wili lateral oblique interlocking screws. No ka hōʻemi ʻana i kēia pilikia, pono e noʻonoʻo ka poʻe kaukō i ka wili ʻana no nā wili ma lalo o ke alakaʻi lima C, me ka huina fluoroscopic o ka lima C e kū pono ana i ka mokulele o ka bit drill. He mea paʻakikī paha ke ʻike ʻia ʻana o ke komo ʻana i loko o ka cortex o ka tibia distal, a ʻo ka hoʻokokoke ʻana o ke poʻo fibular e pohihihi ai i ka manaʻo hoʻoheheʻe a hāʻawi i ke kauka i ka manaʻo ʻo ia ka 'i loko o ka iwi' inā ʻoiaʻiʻo ua komo ke poʻo fibular. Pono e hoʻoholo ʻia ka lōʻihi o ka screw ʻaʻole wale e ka drill graduated akā me nā ana ana hohonu kūpono. ʻO ke ana o ka lōʻihi o ka wili a i ʻole ka wiliwili ʻoi aʻe ma mua o 60 mm pono e hāpai i ka manaʻo kānalua no ka puka ʻana o posterolateral, kahi e hoʻopilikia ai i ke aʻalolo peroneal maʻamau.

Hoʻokomo ʻia nā wiliwili ma mua a me hope me ka nānā ʻana i ka pale o ka pūpū neurovascular anterolateral, tibialis anterior tendon, a me extensor digitorum longus. ʻOiai he palekana ka hoʻokomo ʻana i ka wili percutaneous, pono nā kauka lapaʻau e makaʻala i nā pilikia e pili ana i nā hale palupalu a puni. No ka hapa nui o ka ha'i 'a'a tibial, 'elua mau wili pili kokoke a me 'elua distal i ho'opa'a 'ia. Hiki ke pōmaikaʻi nā haʻihaʻi o ka tibial proximal a me ka distal mai ke kau ʻana i nā wili hoʻopili hou i nā mokulele like ʻole e hoʻonui i ka paʻa o kēia ʻano (Figure 13).

Kiʻi 13. He nui nā haʻihaʻi o ka tibia, i mālama ʻia me ka nailing intramedullary me ʻelua mau ʻoki hoʻopaʻa ʻana a me ʻekolu kokoke, me nā kukui x e hōʻike ana i ka hoʻōla ʻana i ka haʻihaʻi.

-Fibular Fixation

ʻO nā hoʻolālā nail intramedullary o kēia manawa me nā ʻūlū hoʻopaʻa ʻana i hoʻomāhuahua i nā hōʻailona no ka nailing intramedullary o ka tibia e hoʻokomo i nā haʻihaʻi proximal a me ka distal e pili ana i ka ʻāina metaphyseal.

Ua hoʻohana ʻia nā hoʻonohonoho hoʻonohonoho ʻokoʻa hoʻopaʻa ʻokoʻa i loko o ke aʻo ʻana (2 wili mai ka medial a i ka ʻaoʻao ʻaoʻao me 2 mau wili i hoʻonohonoho pono ʻia kekahi i kekahi a me ka huina o 3 mau wiliwili hoʻopaʻa ʻia me 1 wale nō ka wili hoʻopili mamao). I nā poʻe maʻi i loaʻa i ka fibular fixation a me ka tibial intramedullary nail fixation, ʻoi aku ka haʻahaʻa o ka helu o ka nalowale. ʻO ka huina o 13% o nā mea maʻi me ka hoʻoponopono nail intramedullary me ka ʻole o ka fibular fixation i hōʻike i ka nalowale postoperative o ka hoʻoponopono hou ʻana, ke hoʻohālikelike ʻia me 4% o nā maʻi me ka hoʻopaʻa kui tibial me ka hoʻopaʻa ʻole fibular.

I kekahi ho'āʻo e hoʻohālikelike ana i ka pono o ka tibial intramedullary nail fixation versus fibular fixation a me tibial intramedullary nail fixation versus no fibular fixation, nā mea maʻi i mālama ʻia me ka fibular fixation i hui pū ʻia me ka tibial nailing i hōʻike i ka hoʻomaikaʻi ʻana i ka rotational a me ka hoʻohuli / eversion alignment.

Hoʻopau mākou i ka hoʻokō ʻana o ka fibular adjunctive a mālama i ka hoʻohaʻahaʻa ʻana o ka tibial fracture i ka distal hoʻokahi hapakolu o nā tibia fractures e hana ana i ka hoʻoponopono nail intramedullary. Eia nō naʻe, ʻo ka pilikia o nā pilikia ʻeha mai nā ʻoki hou aʻe ma kahi o ka ʻiʻo traumatized e mau nei. No laila ke paipai nei mākou e makaʻala i ka hoʻohana ʻana i ka fibular fixation i kōkua ʻia.

03. Nā hopena

ʻO ka hoʻopaʻa paʻa ʻana o ka nailing intramedullary o nā haʻihaʻi kumu tibial hiki ke loaʻa nā hopena maikaʻi. Ua hōʻike ʻia ka nui o ka ho'ōla ʻana o ka nailing intramedullary o ka tibia i nā haʻawina like ʻole. Me ka hoʻohana ʻana i nā implants hou a me nā ʻano hana ʻoki kūpono, manaʻo ʻia ka nui o ka ho'ōla ma mua o 90%. Ua hoʻomaikaʻi maikaʻi ʻia ka nui o ka ho'ōla ʻana o nā ʻāpana ʻāʻī tibial i hoʻōla ʻole ma hope o ka hoʻopaʻa ʻana i ke kui intramedullary ma hope o ka hoʻopaʻa ʻana i loko me kahi kui intramedullary lua i hoʻonui ʻia.

Ua hōʻike ʻia ka loiloi hopena i hoʻokahi makahiki ma hope o ke ʻoki ʻana a hiki i ka 44% o nā maʻi i hoʻomau i nā palena hana ma ka ʻaoʻao haʻahaʻa i hōʻeha ʻia, a hiki i ka 47% i hoʻomau i ka hōʻike ʻana i ke kīnā e pili ana i ka hana i hoʻokahi makahiki ma hope o ke ʻoki ʻana. Hōʻike ka haʻawina e hoʻomau nā mea maʻi i mālama ʻia me ka nailing intramedullary o ka tibia i nā palena hana nui i ka wā lōʻihi. Pono e ʻike ka poʻe ʻoka i kēia mau pilikia a aʻo i nā poʻe maʻi e like me ia!

四. Nā pilikia postoperative

01. Eha mua o ka patellar

ʻO ka ʻeha patellofemoral mua kahi pilikia maʻamau ma hope o ka hoʻopaʻa ʻana o ka nail intramedullary o nā ʻōpala tibial stem. Ua hōʻike ʻia nā haʻawina ma kahi o 47% o nā mea maʻi ma hope o ke kui intramedullary hiki ke hoʻomohala i ka ʻeha prepatellar, ʻaʻole maopopo ka etiology o ia mea. Hiki ke hoʻokomo ʻia nā mea hiki ke hoʻoulu i ka traumatic a me ka hōʻeha olakino i nā hale intra-articular, ʻeha i ka lālā infrapatellar o ke aʻalolo saphenous, nāwaliwali o nā ʻiʻo ʻūhā lua i ka hoʻopau ʻana i nā neuromuscular reflexes pili i ka ʻeha, fibrosis o ka momona momona e alakaʻi ai i ka impingement, reactive patellar tendonitis, ke kulou ʻana mai ke kui intramedullary a me ka proximal nailing o ka ʻaoʻao o ka ʻaoʻao. ke kui.

Ke aʻo ʻana i ka etiology o ka ʻeha prepatellar ma hope o ke kui intramedullary, ua hoʻohālikelike ʻia ke ʻano o ka tendon transpatellar me ka parapatellar approach. Hiki ke hoʻopili ʻia ke ala o ka tendon transpatellar me kahi kiʻekiʻe o ka ʻeha o ke kuli postoperative. Eia nō naʻe, ʻaʻole i hōʻike ʻia nā ʻikepili lapaʻau prospective randomized i kekahi ʻokoʻa koʻikoʻi ma waena o ke ala tendon transpatellar a me ke ala parapatellar.

ʻAʻole maopopo ka maikaʻi o ka wehe ʻana o ka hoʻoponopono kūloko e hoʻoponopono i ka ʻeha prepatellar ma hope o ka tibial intramedullary nailing. Manaʻo mākou e noʻonoʻo ʻia ka wehe ʻana o ka nail intramedullary tibial inā hiki ke ʻike ʻia kahi etiology mechanical, e like me ka puka ʻana o ke kui a i ʻole ka wili wili. Eia naʻe, ʻo ka pōmaikaʻi o ka wehe ʻana i ke kui intramedullary tibial i nā maʻi symptomatic e kānalua mau.

E pili ana i ka ʻeha prepatellar postoperative, ʻaʻole hiki ke hōʻike maopopo ʻia ke kumu o ka ʻeha i ka hoʻopaʻa ʻana o ka nail intramedullary o ka tibial nail ma ka patella ma ke kūlana semi-extended. No laila, pono nā haʻawina hauʻoli nui me ka hahai lōʻihi e hōʻoia i ka hopena o ka hoʻoponopono nail intramedullary i ka suprapatellar approach ma ka postoperative prepatellar pain.

02.Poor postoperative alignment

He pilikia koʻikoʻi ka osteoarthritis post-traumatic ma hope o ka hoʻomaʻamaʻa ʻana i nā haʻihaʻi kumu tibial me ke kui intramedullary. Ua hōʻike ʻia nā haʻawina biomechanical e hiki i ka tibial malalignment ke hopena i nā loli koʻikoʻi i nā kaomi hoʻopili ʻana ma nā hui kuʻekuʻe a me nā kuli.

ʻO nā haʻawina lāʻau lapaʻau e loiloi ana i nā hopena o ka maʻi a me nā kiʻi kiʻi lōʻihi ma hope o ka haʻihaʻi ʻana o ka tibial stem i hāʻawi i nā ʻikepili kū'ē i ka hopena o ka tibial malalignment, me ka ʻole o nā hopena maopopo a hiki i kēia lā.

ʻO nā hōʻike o ka maʻi maʻi postoperative ma hope o ke kui intramedullary o ka tibia i kaupalena ʻia, me kahi helu liʻiliʻi o nā hihia i hōʻike ʻia. He pilikia maʻamau ka malrotation postoperative i ka tibial intramedullary nailing, a he paʻakikī ka loiloi intraoperative o ka rotation tibial. I kēia lā, ʻaʻole i hoʻokumu ʻia kahi hoʻokolohua lapaʻau a i ʻole ke ʻano kiʻi kiʻi e like me ke kūlana gula no ka hoʻoholo intraoperative o ka rotation tibial. Ua hōʻike ʻia ka loiloi hōʻike hōʻike ʻana i ka nui o ka malrotation ma hope o ke kui intramedullary o ka tibia hiki ke kiʻekiʻe e like me 19% a 41%. ʻO ka mea nui, ʻoi aku ka maʻamau o nā deformations rotation waho ma mua o nā deformation rotation kūloko. Ua hōʻike ʻia ka hoʻokolohua lapaʻau no ka loiloi ʻana i ka malrotation postoperative a hōʻike i ka pilina haʻahaʻa me ka loiloi CT.

Ke manaʻoʻiʻo nei mākou he pilikia lōʻihi ka malalignment i nā haʻihaʻi kumu tibial i mālama ʻia me ke kui intramedullary o ka tibia. ʻOiai ʻo nā ʻikepili kūʻē e pili ana i ka pilina ma waena o ka malalignment a me nā hopena lapaʻau a me nā kiʻi kiʻi, manaʻo mākou e hoʻoikaika nā kauka lapaʻau e hoʻokō i ka alignment anatomic o nā haʻihaʻi i mea e hoʻomalu ai i kēia loli a loaʻa nā hopena maikaʻi loa.

五. Ka hopena

ʻO ka hoʻopaʻa paʻa paʻa i hoʻonui ʻia medullary intramedullary nailing ka mālama maʻamau no ka haʻi ʻia ʻana o ke kumu tibial. He mea koʻikoʻi ka helu komo pololei o ke kaʻina hana. ʻO ke ala suprapatellar ma ke kūlana semi-extended i manaʻo ʻia he kaʻina hana palekana a maikaʻi, a pono e loiloi hou nā haʻawina e hiki mai ana i nā pilikia a me nā pono o kēia kaʻina hana. Pono ke kauka lapaʻau e hele ana i nā ʻenehana hoʻonohonoho hou i kēia manawa. Inā ʻaʻole hiki ke hoʻokō ʻia ka hoʻoponopono ʻana i ka haʻihaʻi anatomic ma o ke ala pani ʻia, pono e noʻonoʻo ʻia nā ʻenehana hōʻemi ʻoki. Hiki ke hoʻokō ʻia ka nui o ka ho'ōla maikaʻi ma mua o 90% me nā kui intramedullary hoʻonui a hoʻonui ʻole ʻia. ʻOiai ka maikaʻi o ka ho'ōla ʻana, loaʻa i nā maʻi nā palena hana lōʻihi. ʻO ka mea nui, he hoʻopiʻi maʻamau ka ʻeha prepatellar ma hope o ka nailing intramedullary tibial. Eia kekahi, ʻo ka malrotation ma hope o ka hoʻopaʻa ʻana o ka tibial i loko he pilikia maʻamau.

Nā kuhikuhi

1. E aʻo e loiloi i ka Reamed Intramedullary Nails i nā poʻe maʻi me nā mea noiʻi ʻo Tibial Fractures. Bhandari M, Guyatt G, Tornetta P, III, Schemitsch EH, Swiontkowski M, et al. ʻO ka hoʻāʻo ʻokoʻa o ka reamed a me ka unreamed intramedullary nailing o nā haʻihaʻi kumu tibial. J Iwi Huipuia Surg Am. 2008;90:2567–2578. doi: 10.2106/JBJS.G.01694.

2.McQueen MM, Duckworth AD, Aitken SA, Sharma R, Court-Brown CM. Nā wānana o ka compartment syndrome ma hope o ka haki ʻana o tibial. J Orthop Trauma. 2015. [Epub ma mua o ka paʻi].

3.Park S, Ahn J, Gee AO, Kuntz AF, Esterhai JL. ʻO ka maʻi maʻi i loko o nā haʻihaʻi tibial. J Orthop Trauma. 2009;23:514–518. doi: 10.1097/BOT.0b013e3181a2815a.

4.McQueen MM, Aha-Brown CM. Ka nānā ʻana o ke keʻena i nā haʻihaʻi tibial. ʻO ka paepae kaomi no ka decompression. J Bone Joint Surg (Br) 1996;78:99–104.

5.McQueen MM, Duckworth AD, Aitken SA, Court-Brown CM. ʻO ka manaʻo i manaʻo ʻia a me ka kikoʻī o ka nānā ʻana i ke kaomi compartment no ka maʻi koʻikoʻi compartment. J Iwi Huipuia Surg Am. 2013;95:673–677. doi: 10.2106/JBJS.K.01731.

6.Whitesides TE, Jr, Haney TC, Morimoto K, Harada H. ʻO nā ana kaomi ʻana o ke kino ma ke ʻano he mea hoʻoholo no ka pono o ka fasciotomy. Clin Orthop. 1975;113:43–51. doi: 10.1097/00003086-197511000-00007.

7.Kakar S, Firoozabadi R, McKean J, Tornetta P., 3rd Diastolic blood pressure i nā maʻi me ka tibia fractures ma lalo o ka anesthesia: nā hopena no ka hōʻailona o ka maʻi o ka compartment. J Orthop Trauma. 2007;21:99–103. doi: 10.1097/BOT.0b013e318032c4f4.

8.Purnell GJ, Glass ER, Altman DT, Sciulli RL, Muffly MT, Altman GT. Nā hopena o kahi protocol tomography i helu ʻia e loiloi ana i nā haʻihaʻi lāʻau tibial ʻekolu e nānā i nā haʻihaʻi malleolar noncontiguous. J Poeha. 2011;71:163–168. doi: 10.1097/TA.0b013e3181edb88f.

9.Buehler KC, Green J, Woll TS, Duwelius PJ. He ʻano hana no ka nailing intramedullary o nā haʻihaʻi ʻekolu o ka tibia proximal. J Orthop Trauma. 1997;11:218–223. doi: 10.1097/00005131-199704000-00014.

10.McConnell T, Tornetta P, III, Tilzey J, Casey D. Hoʻokomo i ka puka puka ʻo Tibial: ʻo ka radiographic correlate o ka anatomic safe zone. J Orthop Trauma. 20

01;15:207–209. doi: 10.1097/00005131-200103000-00010 .etc......