Tibial Intramedullary Nail Fixation Technique

Intramedullary ntsia thawv fixation tseem yog cov kev kho mob ntawm kev xaiv rau tsis ruaj tsis khov thiab tshem tawm tibial qia fractures nyob rau hauv cov neeg laus. Lub hom phiaj ntawm kev kho mob phais yog los kho qhov ntev, kev sib tw thiab kev sib hloov ntawm tibia thiab ua tiav kev kho pob txha. Qhov zoo ntawm intramedullary nailing yog qhov kev phais tsawg kawg nkaus thiab tsim nyog khaws cov ntshav txaus rau pob txha. Tsis tas li ntawd, intramedullary nailing ntawm tibia muab qhov tsim nyog biomechanical puas ntsoog ruaj khov thiab ua raws li cov khoom sib koom ua ke tso cai rau kev ua haujlwm thaum ntxov. Kev nce qib hauv intramedullary ntsia thawv tsim thiab txo cov tswv yim tau nthuav dav cov kev qhia rau intramedullary ntsia thawv fixation kom muaj xws li tibia proximal thiab qis nruab nrab peb pob txha.

Txog rau hnub no, kaw txo qis intramedullary ntsia thawv kho ntawm tibial pob txha tau dhau los ua cov txheej txheem rau cov kws phais neeg mob orthopedic. Txawm hais tias muaj koob meej ntawm intramedullary ntsia thawv fixation rau qhov chaw tibial qia tawg, nws tseem nyuaj thiab muaj ntau yam teeb meem. Cov txheej txheem phais mob txuas ntxiv mus. Lub hom phiaj ntawm tsab xov xwm no yog los piav qhia txog cov ntsiab lus tam sim no hauv kev kho cov ntsia hlau intramedullary ntawm tibial qia fractures thiab sau cov ntsiab lus tsis ntev los no hauv thaj chaw.

Ib. Kev ntsuam xyuas pib thiab tshuaj xyuas

Hauv cov neeg mob hluas, cov pob txha tibial feem ntau yog tshwm sim los ntawm kev raug mob siab zog, thiab cov neeg mob yuav tsum raug soj ntsuam rau kev raug mob raws li Advanced Trauma Life Support (ATLS) cov lus qhia. Ntsuas cov tawv nqaij ib puag ncig thiab cov nqaij mos raug mob xws li pob txha pob txha, tawv nqaij abrasions, kub hnyiab, ecchymosis, lossis tawv nqaij; qhia meej seb puas yog pob txha qhib, thiab yog tias kho nrog tetanus thiab tshuaj tua kab mob; thiab ua ib qho kev kuaj mob neurovascular zoo thiab sau cov ntaub ntawv saum toj no. Ntsuam xyuas qhov tshwm sim ntawm osteofascial compartment syndrome thiab ua ntau yam kev kuaj mob hauv cov neeg mob no.

Cov kev tshawb fawb tsis ntev los no tau pom tias qhov tshwm sim ntawm osteofascial compartment syndrome tom qab tibial tuberosity pob txha yuav siab li 11.5%. Hauv particular, cov neeg mob hluas feem ntau yuav tsim cov kab mob osteofascial compartment. Kev kuaj mob ntawm osteofascial compartment syndrome yuav tsum yog raws li kev tshawb fawb soj ntsuam, nrog rau qhov mob hnyav, kev hloov pauv hauv cov hlab ntsha, o ntawm myofascial compartment, thiab mob hnyav ntxiv los ntawm cov ntiv taw txuas ntxiv. Yog li ntawd, osteofascial compartment syndrome tseem yog ib qho kev kuaj mob thiab cov ntaub ntawv meej ntawm kev kuaj mob yog qhov tseem ceeb. Lub siab nyob rau hauv lub myofascial compartment tuaj yeem ntsuas los ntawm kev siv rab koob siab (Daim duab 1) raws li ib qho kev xeem ntxiv rau kev kuaj mob tshwj xeeb.

Daim duab 1. Kev ntsuas lub siab nyob rau hauv interosseous septum los ntawm kev siv rab koob siab

Txhawm rau kom tau txais cov ntaub ntawv txhim khu kev qha, cov kev kub siab intrafascial yuav tsum tau ntsuas nyob rau hauv plaub lub myofascial compartments thiab ntawm qhov chaw sib txawv hauv txhua qhov chaw hauv myofascial. Cov kev tshawb fawb hauv cov ntaub ntawv qhia tias qhov sib txawv ntawm qhov siab ntawm tsawg dua 30 mmHg (diastolic siab rho tawm fascial compartment siab) qhia tau tias muaj fascial compartment syndrome. Diastolic siab feem ntau yuav txo qis thaum lub sij hawm phais, thiab preoperative diastolic siab yuav tsum tau coj mus rau hauv tus account thaum xam qhov sib txawv siab.

Cov kev tshawb fawb tsis ntev los no tau pom tias kev saib xyuas lub siab intrafascial yog ib qho cuab yeej muaj txiaj ntsig zoo rau kev kuaj mob ntawm tus mob fascial compartment syndrome, nrog rau qhov rhiab heev ntawm 94% thiab qhov tshwj xeeb ntawm 98%. Txawm li cas los xij, vim tias qhov ua rau muaj kev puas tsuaj loj heev ntawm cov kab mob compartment syndrome, kev kuaj mob ntawm cov kab mob compartment yuav tsum yog raws li kev tshawb fawb soj ntsuam, thiab kev ntsuas lub siab ntawm lub cev yuav tsum tau siv rau qhov xwm txheej tshwj xeeb, xws li thaum tus neeg mob raug mob lossis thaum cov ntaub ntawv kho mob tsis meej.

Kev ntsuam xyuas cov duab yuav tsum suav nrog cov qauv orthopantomograms thiab lateral views ntawm cov neeg raug mob tibia thiab cov duab hluav taws xob ntawm lub hauv caug thiab pob taws uas nyob ib sab, uas tau soj ntsuam ntxiv nrog kev suav tomography (CT). Ib yam li ntawd, CT scan ntawm pob taws yuav tsim nyog kom pom cov kab tawg uas txuas mus rau tibial toj siab thiab cuam tshuam cov pob taws tsis sib xws.

二. Clinical pitfalls

Ib feem pua ​​​​ntawm cov pob txha ntawm qhov qis nruab nrab ntawm peb ntawm tibia nrog pob taws pob taws tau raug tshaj tawm. Siv cov qauv CT scans, 43% ntawm cov pob txha ntawm nruab nrab thiab qis thib peb ntawm tibia tau nrog pob taws pob txha, feem ntau ntawm cov kev kho mob phais. Hom pob txha feem ntau yog cov pob txha pob txha ntawm qhov qis nruab nrab ntawm peb ntawm lub distal tibia cuam tshuam nrog me ntsis lossis tsis muaj qhov chaw nyob tom qab pob taws pob taws (Daim duab 2). Vim yog qhov me me ntawm qhov cuam tshuam pob qij txha, tsuas yog 45% ntawm kev raug mob tuaj yeem kuaj pom ntawm pob taws pob taws. Yog li ntawd, niaj hnub CT scans ntawm pob taws yuav tsum tau hais meej heev thaum muaj qhov qis nruab nrab ntawm tibia pob txha tawg (Daim duab 3).

Daim duab 2.AF Kauv pob txha ntawm qhov qis nruab nrab thib peb ntawm txoj cai tibia (A, B) Preoperative radiographs ntawm pob taws qhia qhov qub (C). Intraoperative C-arm fluoroscopy qhia tau hais tias tsis muaj kev puas tsuaj ntawm pob qij txha tom qab (D) Postoperative radiographs tom qab phais kho (EF) qhia kev kho kom zoo ntawm tibial thiab pob taws pob taws.

Daim duab 3. AF Kauv pob txha ntawm nruab nrab thiab qis thib peb ntawm sab laug tibia (AB) preoperative radiographs; (CD) preoperative CT scans qhia ib qho tsis muaj chaw nyob tom qab malleolar puas; (EF) qhia kev kho tsis zoo ntawm tibia thiab malleolar pob txha

ḉ. Txoj kev phais

01. Tibial Needle Entry Point

Tsim kom muaj qhov tseeb nkag mus ua lub luag haujlwm tseem ceeb thiab ntau qhov kev tshawb fawb hauv cov ntaub ntawv tau muab cov ntaub ntawv tseem ceeb ntawm qhov chaw anatomical ntawm qhov zoo tshaj plaws nkag rau hauv intramedullary nailing ntawm tibial pob txha. Cov kev tshawb fawb no tau pom tias qhov zoo tshaj plaws pinning point yog nyob rau ntawm lub anterior margin ntawm tibial toj siab thiab tsuas yog medial mus rau sab tibial spur. Ib cheeb tsam kev nyab xeeb nrog qhov dav ntawm 22.9 hli ± 8.9 hli, uas tsis ua rau muaj kev puas tsuaj rau cov qauv sib txuas uas nyob ib sab, kuj tau tshaj tawm. Kev lig kev cai, qhov pib ntawm intramedullary ntsia thawv fixation ntawm tibial qia fractures tau tsim los ntawm ib qho infrapatellar mus kom ze, los ntawm kev faib cov patellar tendon (transpatellar mus kom ze) los yog stripping ib feem ntawm patellar tendon nres (paratendinous mus kom ze).

Semi-extension intramedullary nailing tau nyiam ntau yam nyob rau hauv cov ntaub ntawv orthopedic tsis ntev los no, thiab Tornetta thiab Collins qhia siv txoj hauv kev nruab nrab parapatellar rau kev kho sab hauv ntawm tus ntsia thawv nyob rau hauv txoj hauj lwm semi-extension kom tsis txhob protrusion ntawm lub apex ntawm tus ntsia thawv intramedullary mus rau hauv lub anterior tibial cortexary cortex. nailing nyob rau hauv txoj hauj lwm semi-extension kuj pom zoo. Kev siv cov suprapatellar mus kom ze rau tibial intramedullary nailing thiab tso rau ntawm tus ntsia thawv intramedullary los ntawm patellofemoral sib koom hauv txoj hauj lwm semi-extended yog pom zoo.

Cov txheej txheem yog ua nrog lub hauv caug flexed ntawm kwv yees li 15-20 degrees, thiab ib tug longitudinal incision ntawm kwv yees li 3 centimeters yog ua kwv yees li ib mus rau ob tug ntiv tes dav saum lub patella. Lub quadriceps tendon yog cais nyob rau hauv ib tug longitudinal zam thiab blunt dissection yog ua nyob rau hauv lub patellofemoral sib koom. Lub qhov (socket) blunt yog muab tso rau hauv lub patellofemoral sib koom ua ke los tsim ib qho chaw nkag ntawm qhov sib txuas ntawm lub anterior tibial cortex thiab articular nto (Daim duab 4).

Daim duab 4. ab Intraoperative duab ntawm (a) splitting lub quadriceps tendon thiab inserting lub trocar los ntawm lub patellofemoral sib koom mus rau tibial nkag point; (b) intraoperative lateral saib ntawm qhov chaw nkag

Ib tug 3.2 hli laum ntsis yog siv los txiav txim qhov pib koob taw tes raws li C-arm qhia. Ib lub qhov (socket) perforated yog muab los kho qhov nkag thiab tawm cov ntsiab lus. Cov txheej txheem phais ntxiv nrog rau reaming thiab tibial ntsia thawv ntxig yog ua los ntawm lub qhov (socket).

TSEEM CEEB TSHAJ PLAWS: Txoj hauj lwm semi-extended ceg yuav pab tau pob txha repositioning, tshwj xeeb tshaj yog nyob rau hauv fractures nrog ib tug raug proximal peb ntawm tibia thiab angled rau pem hauv ntej. , Txoj hauj lwm semi-extended tej zaum yuav tshem tawm qhov nro ntawm cov leeg quadriceps thiab pab hauv pob txha repositioning. , Lub semi-extended txoj hauj lwm suprapatellar mus kom ze kuj yuav yog ib qho kev xaiv rau cov tsoos infrapatellar mus kom ze (Daim duab 5).

Daim duab 5. Intraoperative daim duab qhia cov nqaij mos raug mob nyob rau hauv cheeb tsam infrapatellar raws li ib qho kev qhia rau ib tug suprapatellar mus kom ze nyob rau hauv ib tug semi-extended txoj hauj lwm.

Cov kev tshawb fawb tau pom tias txoj hauv kev suprapatellar rau tibial intramedullary nailing nyob rau hauv txoj hauj lwm semi-extended yog ib qho kev nyab xeeb thiab siv tau zoo. Kev sim tshuaj ntsuam xyuas yav tom ntej yog xav tau los tshawb xyuas qhov zoo thiab qhov tsis zoo ntawm suprapatellar txoj hauv kev intramedullary nailing thiab ntsuas cov txiaj ntsig mus sij hawm ntev cuam tshuam nrog cov txheej txheem no.

02. Rov kho tshuab

Qhov chaw ntawm tibial intramedullary ntsia thawv ib leeg tsis ua rau kom txaus pob txha; Kev txo cov pob txha kom raug yuav tsum tau khaws cia thoob plaws hauv cov txheej txheem reaming thiab intramedullary ntsia thawv tso. Daim ntawv thov ntawm phau ntawv traction ib leeg yuav tsis tas yuav ua tiav qhov kev txo qis ntawm cov pob txha los ntawm nws tus kheej. Kab lus no yuav piav qhia txog ntau yam ntawm kev kaw, qhov cuam tshuam tsawg kawg nkaus, thiab qhib kev txo qis maneuvers.

- Kaw rov pib txheej txheem cov lus qhia

Kaw txo maneuvers tuaj yeem ua tiav nrog cov cuab yeej txo qis xws li F-fracture reducer, F-shaped radiographically transmissible txo cov cuab yeej uas kho rau cov kaum sab xis ntawm kev hloov pauv / hloov pauv nrog rau kev txhais lus nruab nrab / sab nraud (Fig. 6).

Fig. 6. F-shaped fracture reducer hais hauv kev phais

Txawm li cas los xij, cov cuab yeej tuaj yeem ua rau muaj kev ntxhov siab loj rau ntawm cov ntaub so ntswg, thiab kev siv lub sijhawm ntev ntawm cov khoom siv no yuav tsum raug zam. Txo cov forceps tuaj yeem muab tso rau hauv percutaneously, xws li nyob rau hauv cov ntaub ntawv ntawm kauv thiab oblique puas. Cov cuab yeej no tuaj yeem siv rau hauv cov ntaub so ntswg mos los ntawm kev txiav me me (Daim duab 7).

Daim duab 7. Percutaneous clamping los pib dua ib qho kev puas tsuaj tibial

Hom clamp thiab qhov chaw ntawm qhov kev phais phais yuav tsum raug xaiv raws li lub tswv yim kom txo qis kev puas tsuaj mus sij hawm ntev rau cov ntaub so ntswg los ntawm qhov chaw clamp (Daim duab 8).

Fig. 8. Pointed repositioning forceps los pib dua tibial pob txha

Retractors kuj yog ib qho ntawm cov cuab yeej kho dua qub uas siv los kho qhov ntev rau tibia. Lawv feem ntau yog muab tso rau hauv nruab nrab thiab deb ntawm qhov chaw uas yuav tsum tau muab cov ntsia hlau intramedullary. Proximal traction pins tuaj yeem muab tso rau kom ua raws li qhov sib thooj thaiv qhov ntsia hlau txoj haujlwm, uas tso cai rau kom yooj yim txo qhov tawg thaum tus ntsia thawv intramedullary nyob rau hauv.

Qee qhov xwm txheej, cov txheej txheem kaw thiab txo qis qis qis tseem tsis txaus kom tau txais kev txo qis hauv lub cev. Nyob rau hauv xws li mob, incisional txo cov txheej txheem yuav tsum tau txiav txim siab nrog ceev faj tswj ntawm ib puag ncig cov ntaub so ntswg. Tej yam tsis zoo ntawm kev qhib kev txo qis muaj xws li kev phais mob ntxiv, uas yuav ua rau muaj kev pheej hmoo ntawm qhov chaw phais mob. Tsis tas li ntawd, kev tshem tawm cov ntshav ntxiv mus rau qhov chaw tawg tuaj yeem ua rau muaj kev pheej hmoo ntawm postoperative fracture nonunion.

-Technical Skills for Incision thiab Repositioning

Incisional reduction maneuvers tso cai tsis yog tsuas yog phais txo cov forceps tso rau hauv txoj hauj lwm kom zoo, tab sis kuj siv cov me me los yog me me splints ntawm qhov chaw tawg kom muaj kev txo qis hauv cov txheej txheem intramedullary nailing.

Cov phaj muaj kev ruaj ntseg rau qhov sib thooj thiab qhov tawg tawg tawg uas siv cov ntsia hlau monocortical. Lub splint yog khaws cia thoob plaws hauv cov txheej txheem ntawm reaming thiab tso rau ntawm tus ntsia thawv intramedullary hauv tibia. Tom qab muab tso rau ntawm tus ntsia thawv intramedullary, lub phaj raug tshem tawm los yog tso rau hauv qhov chaw kom txhim khu kev ruaj ntseg ntawm cov qauv ruaj (Daim duab 9). Los ntawm kev tawm ntawm lub phaj nyob rau hauv qhov chaw, ib qho cortical ntsia hlau yuav tsum tau hloov nrog ob lub cortical ntsia hlau. Nws yuav tsum raug txiav txim siab siv rau hauv cov rooj plaub uas tus tibial qia yuav tsum tau qhib kev phais kom ua tiav qhov kev txo cov pob txha.

Daim duab 9. Qhib tibia pob txha tawg nrog kev sib tsoo loj heev thiab cov pob txha tsis xws luag, ib qho cortical fixation nrog me me splint ntawm qhov kawg ntawm cov pob txha tawg tom qab txo qis thiab tshem tawm cov splint tom qab intramedullary ntsia thawv kho.

Lub hom phiaj ntawm kev thaiv cov ntsia hlau yog nqaim lub medullary kab noj hniav hauv thaj tsam metaphyseal. Thaiv cov ntsia hlau yog muab tso rau hauv qhov luv luv articular fragment thiab nyob rau sab concave ntawm deformity ua ntej intramedullary ntsia thawv tso. Piv txwv li, qhov raug deformity ntawm pob txha ntawm qhov sib thooj thib peb ntawm tibia yog tus cwj pwm los ntawm valgus thiab pem hauv ntej angulation. Txhawm rau kho lub valgus deformity, lub xauv ntsia hlau tuaj yeem muab tso rau hauv qhov chaw sab nraud ntawm qhov sib thooj ntawm qhov tawg tawg (piv txwv li, sab concave ntawm deformity) nyob rau hauv ib qho kev taw qhia anteroposterior. Tus ntsia thawv intramedullary yog coj los ntawm sab nruab nrab, yog li tiv thaiv valgus. Ib yam li ntawd, angulation deformity tuaj yeem kov yeej los ntawm kev tso lub xauv ntsia hlau nruab nrab mus rau sab tom qab mus rau qhov chaw tom qab ntawm qhov sib thooj (piv txwv li, sab concave ntawm deformity) (Daim duab 10).

Daim duab 10. pab rov pib dua ntawm tibial pob txha los ntawm qhov chaw ntawm thaiv cov rau tes

- Medullary expansion

Tom qab ua tiav cov pob txha repositioning, medullary reaming yog xaiv los npaj cov pob txha rau intramedullary ntsia thawv insertion. Lub pob-kawg guidewire tau muab tso rau hauv tibial pob txha kab noj hniav thiab los ntawm qhov chaw tawg, thiab cov laum reaming tau dhau los ntawm pob-kawg guidewire. Txoj hauj lwm ntawm lub pob-kawg guidewire tau lees paub nyob rau hauv C-arm fluoroscopy kom nyob rau theem ntawm pob qij txha, thiab cov lus qhia tau zoo nyob rau ntawm ob qho tib si anteroposterior thiab lateral views (Daim duab 11).

Daim duab 11. qhia txog txoj hauj lwm ntawm tus taw qhia txoj kab noj hniav nyob rau hauv medullary kab noj hniav ntawm C-arm fluoroscopy nyob rau hauv lub frontal thiab lateral txoj hauj lwm

Qhov teeb meem ntawm kev nthuav tawm piv rau qhov tsis nthuav dav medulla tau muaj teeb meem. Peb ntseeg hais tias feem ntau cov kws phais nyob rau hauv North America nyiam nthuav medullary intramedullary nailing ntawm tibia kom tsis-expanded. Txawm li cas los xij, ob qho tib si nthuav dav thiab tsis nthuav dav intramedullary nailing tuaj yeem siv los ua cov txheej txheem tsim nyog, thiab cov txiaj ntsig zoo tuaj yeem tau txais nrog ob txoj hauv kev.

- Xauv ntsia hlau tso

Kev siv cov ntsia hlau sib txuas hauv tibial qia pob txha yog tsim los tiv thaiv luv luv thiab malrotation, txuas ntxiv cov lus qhia rau intramedullary nailing ntawm tibia mus rau ntau qhov sib thooj thiab qhov nruab nrab tibial qia pob txha uas cuam tshuam nrog metaphysis. Hauv kev puas tsuaj uas cuam tshuam nrog thaj tsam metaphyseal, interlocking screws tau dhau los ua qhov tseem ceeb hauv kev tswj cov axial alignment.

Peb cov ntsia hlau sib txuas sib txuas tau zoo txhim kho kev ruaj ntseg, thiab lub kaum ntse ntse sib cuam tshuam cov ntsia hlau tuaj yeem muab kev ruaj ntseg ntau dua li cov qauv sib txuas sib txuas, uas tuaj yeem tso cai rau tib yam kev ruaj ntseg kom tau txais nrog tsawg dua ntawm cov ntsia hlau sib txuas. Cov ntaub ntawv kho mob ntawm tus lej thiab kev teeb tsa ntawm kev sib tshuam cov ntsia hlau xav tau rau kev kho sab hauv ntawm tibia tseem txwv.

Qhov chaw ntawm qhov sib txuas sib txuas ntawm cov ntsia hlau feem ntau yog ua los ntawm kev siv ib qho kev txuas nrog rau cov ntsia hlau intramedullary ntsia hlau loj. Distal interlocking screws yog muab tso rau hauv freehand nyob rau hauv fluoroscopic kev taw qhia. Kev siv lub tshuab hluav taws xob hluav taws xob hauv computer-pab txoj kev taw qhia yog pom zoo rau kev ntxig ntawm cov tibial interlocking screws (Daim duab 12). Cov txheej txheem no tso cai rau cov hluav taws xob tsis muaj hluav taws xob tso rau ntawm qhov sib txuas ntawm cov ntsia hlau distal thiab tau pom tias yog txoj hauv kev ua tau thiab raug.

Daim duab 12.AB Xauv screws ntawm C-arm foundations; CD Locking screws ntawm electromagnetic computer-pab locking

Qhov chaw ntawm qhov sib thooj thiab qhov distal interlocking screws yog txoj kev phais kev nyab xeeb thiab cov ntsia hlau sib txuas yuav tsum tau muab tso rau hauv cov ntaub so ntswg zoo thiab zoo.

Cov kev tshawb fawb Anatomic tau pom tias tseem muaj kev pheej hmoo ntawm cov hlab ntsha peroneal palsy thaum muab qhov nruab nrab nruab nrab mus rau oblique interlocking screws. Txhawm rau txo qhov kev pheej hmoo no, cov kws phais yuav tsum xav txog qhov drilling rau cov ntsia hlau raws li C-arm kev taw qhia, nrog lub fluoroscopic kaum sab xis ntawm C-arm perpendicular rau lub dav hlau ntawm lub laum me ntsis. Kev nkag mus rau hauv lub cortex ntawm lub distal tibia tej zaum yuav nyuaj rau kev nkag siab los ntawm kev tawm tswv yim tactile, thiab qhov ze ze ntawm lub taub hau fibular yuav ua rau pom tsis meej lub tswv yim tactile thiab ua rau tus kws phais lub tswv yim ntawm kev ua 'hauv pob txha' thaum qhov tseeb lub taub hau fibular tau nkag mus. Screw ntev yuav tsum tau txiav txim siab tsis yog los ntawm kev xyaum kawm tiav xwb tab sis kuj los ntawm kev ntsuas qhov tob kom tsim nyog. Ib qho kev xyaum los yog qhov ntsuas qhov ntev ntau dua 60 hli yuav tsum ua rau muaj kev tsis txaus ntseeg ntawm posterolateral protrusion, uas yuav ua rau cov paj hlwb peroneal feem ntau raug mob.

Distal anterior thiab posterior interlocking screws yog muab tso nrog kev saib xyuas rau kev tiv thaiv ntawm anterolateral neurovascular bundle, tibialis anterior leeg, thiab extensor digitorum longus. Txawm hais tias percutaneous ntsia hlau qhov chaw feem ntau muaj kev nyab xeeb, cov kws phais yuav tsum paub txog cov kev pheej hmoo ntawm cov ntaub so ntswg nyob ib puag ncig. Rau feem ntau tibial qia fractures, ob lub proximal thiab ob distal interlocking screws muab kev ruaj ntseg txaus. Proximal thiab distal tibial fractures tuaj yeem tau txais txiaj ntsig los ntawm kev tso cov ntsia hlau txuas ntxiv hauv cov dav hlau sib txawv kom muaj kev ruaj ntseg ntawm cov qauv no (Daim duab 13).

Daim duab 13. Ntau qhov pob txha ntawm tibia, kho nrog cov ntsia hlau intramedullary nrog ob lub distal thiab peb qhov sib txuas sib txuas, nrog rau x-rays qhia txog kev kho pob txha.

- Fibular Fixation

Niaj hnub nimno intramedullary ntsia thawv tsim nrog distal interlocking screws tau nthuav dav cov lus qhia rau intramedullary nailing ntawm tibia kom suav nrog cov pob txha thiab qhov nruab nrab uas cuam tshuam nrog thaj tsam metaphyseal.

Kev sib txawv distal interlocking ntsia hlau configurations tau siv nyob rau hauv txoj kev tshawb no (2 screws los ntawm nruab nrab mus rau lateral tiv thaiv 2 screws tso perpendicular rau ib leeg thiab tag nrho ntawm 3 distal interlocking screws piv rau 1 distal interlocking ntsia hlau). Nyob rau hauv cov neeg mob uas underwent fibular fixation thiab tibial intramedullary ntsia thawv fixation, tus nqi ntawm poob rov qab yog ho txo. Tag nrho ntawm 13% ntawm cov neeg mob nrog intramedullary ntsia thawv fixation yam tsis muaj fibular fixation pom tom qab poob ntawm rov pib dua, piv nrog rau 4% ntawm cov neeg mob uas tibial ntsia thawv fixation tsis muaj fibular fixation.

Hauv lwm qhov kev sim sib piv cov txiaj ntsig ntawm tibial intramedullary ntsia thawv fixation piv rau fibular fixation thiab tibial intramedullary ntsia thawv fixation piv tsis muaj fibular fixation, cov neeg mob kho nrog fibular fixation nyob rau hauv ua ke nrog tibial nailing pom kev txhim kho nyob rau hauv rotational thiab inversion / eversion alignment.

Peb txiav txim siab tias kev kho cov fibular tau ua tiav thiab tswj xyuas tibial pob txha txo qis hauv cov pob txha ib feem peb ntawm tibia cov pob txha ua rau cov ntsia thawv kho mob intramedullary. Txawm li cas los xij, qhov teeb meem ntawm qhov txhab mob los ntawm kev phais ntxiv hauv thaj tsam ntawm cov ntaub so ntswg tseem nyob. Yog li ntawd, peb pom zoo kom ceev faj siv cov kev pab cuam fibular fixation.

03. Kev tshwm sim

Intramedullary nailing fixation ntawm tibial qia pob txha tuaj yeem ua tau zoo. Kev kho tus nqi ntawm intramedullary nailing ntawm tibia tau tshaj tawm nyob rau hauv kev tshawb fawb sib txawv. Nrog rau kev siv cov cog cog niaj hnub no thiab cov txheej txheem phais tsim nyog, cov nqi kho mob yuav tsum siab dua 90%. Kev kho tus nqi ntawm tibial qia pob txha uas ua tsis tau zoo tom qab intramedullary ntsia thawv kho tau zoo heev tom qab kho nrog tus ntsia thawv thib ob nthuav dav intramedullary.

Cov txiaj ntsig kev ntsuam xyuas ntawm ib xyoos tom qab kev phais tau pom tias txog li 44% ntawm cov neeg mob txuas ntxiv muaj kev txwv tsis pub ua haujlwm hauv cov neeg mob qis qis, thiab txog li 47% txuas ntxiv qhia txog kev ua haujlwm tsis taus ntawm ib xyoos tom qab kev phais. Txoj kev tshawb no qhia tias cov neeg mob kho nrog intramedullary nailing ntawm tibia txuas ntxiv muaj kev txwv tsis pub ua haujlwm hauv lub sijhawm ntev. Cov kws phais yuav tsum paub txog cov teeb meem no thiab qhia cov neeg mob raws li!

四. Postoperative teeb meem

01. Pre-patellar mob

Anterior patellofemoral mob yog ib qho teeb meem tshwm sim tom qab intramedullary ntsia thawv fixation ntawm tibial qia pob txha. Cov kev tshawb fawb tau pom tias kwv yees li 47% ntawm cov neeg mob tom qab intramedullary nailing tuaj yeem tsim mob prepatellar, qhov etiology uas tsis to taub tag nrho. Tej yam muaj feem cuam tshuam tej zaum yuav muaj xws li kev raug mob thiab kev kho mob raug mob rau cov kab mob hauv lub cev, kev raug mob rau infrapatellar ceg ntawm lub paj hlwb saphenous, tsis muaj zog ntawm tus ncej puab cov leeg thib ob rau kev tiv thaiv ntawm qhov mob ntsig txog neuromuscular reflexes, fibrosis ntawm cov roj pad ua rau impingement, reactive patellar tendonitis, los ntawm kev cuam tshuam ntawm kev sib txuas ntawm cov ntsia hlau. tibia, thiab protrusion ntawm proximal kawg ntawm tus ntsia thawv.

Thaum kawm txog etiology ntawm prepatellar mob tom qab intramedullary nailing, transpatellar tendon mus kom ze tau muab piv nrog parapatellar mus kom ze. Txoj hauv kev transpatellar tendon tuaj yeem cuam tshuam nrog qhov tshwm sim ntau dua ntawm kev mob hauv caug tom qab phais. Txawm li cas los xij, cov ntaub ntawv kho mob yav tom ntej randomized tsis pom qhov sib txawv ntawm qhov transpatellar tendon mus kom ze thiab parapatellar mus kom ze.

Qhov ua tau zoo ntawm kev xaiv tshem tawm ntawm kev kho sab hauv los daws qhov mob prepatellar tom qab tibial intramedullary nailing yog tsis paub tseeb. Peb pom zoo kom tshem tawm cov ntsia hlau intramedullary tibial yog tias tus neeg kho tshuab etiology tuaj yeem txheeb xyuas tau, xws li tus ntsia thawv protrusion los yog cov ntsia hlau txuas txuas. Txawm li cas los xij, qhov txiaj ntsig ntawm tibial intramedullary ntsia thawv tshem tawm hauv cov neeg mob cov tsos mob tseem muaj lus nug.

Hais txog kev mob ntshav qab zib prepatellar, qhov ua rau ntawm qhov mob tsis tuaj yeem ua kom pom tseeb hauv kev tshawb fawb thawj zaug ntawm intramedullary ntsia thawv fixation ntawm tibial ntsia thawv rau ntawm patella nyob rau hauv txoj hauj lwm semi-extended. Yog li ntawd, cov kev tshawb fawb loj loj nrog kev soj ntsuam mus sij hawm ntev yog tsim nyog los xyuas kom meej tias cov nyhuv ntawm intramedullary ntsia thawv fixation nyob rau hauv lub suprapatellar mus kom ze rau postoperative prepatellar mob.

02.Kev ua haujlwm tsis zoo tom qab kev sib raug zoo

Post-traumatic osteoarthritis tseem yog ib qho teeb meem tseem ceeb tom qab kev kho mob ntawm tibial qia pob txha nrog intramedullary nailing. Cov kev tshawb fawb biomechanical tau pom tias tibial malalignment tuaj yeem ua rau muaj kev hloov pauv loj hauv kev sib cuag ntawm cov pob taws thiab pob qij txha uas nyob ib sab.

Cov kev tshawb fawb soj ntsuam ntsuam xyuas cov kev soj ntsuam mus sij hawm ntev thiab kev ntsuam xyuas cov txiaj ntsig tom qab tibial qia tawg tau muab cov ntaub ntawv tsis sib haum xeeb ntawm cov sequelae ntawm tibial malalignment, tsis muaj cov lus xaus rau hnub tim.

Cov ntawv ceeb toom ntawm kev ua haujlwm tsis zoo tom qab kev phais mob ntawm tus tibia tseem txwv, nrog qee tus neeg mob tau tshaj tawm. Postoperative malrotation tseem yog ib qho teeb meem tshwm sim hauv tibial intramedullary nailing, thiab intraoperative ntsuam xyuas ntawm tibial rotation tseem nyuaj. Txog rau tam sim no, tsis muaj kev kuaj mob lossis kev tshuaj ntsuam xyuas tau raug tsim los ua tus qauv kub rau kev txiav txim siab ntawm tibial rotation.CT kev ntsuam xyuas tau pom tias tus nqi ntawm malrotation tom qab intramedullary nailing ntawm tibia yuav siab li 19% mus rau 41%. Hauv particular, sab nraud rotation deformities tshwm sim ntau tshaj li internal rotation deformities. Kev kuaj mob rau kev soj ntsuam tom qab kev ua haujlwm tsis zoo tau tshaj tawm tias tsis raug thiab pom tias muaj kev sib raug zoo nrog CT kev ntsuam xyuas.

Peb ntseeg hais tias malalignment tseem yog ib qho teeb meem mus sij hawm ntev nyob rau hauv tibial qia fractures kho nrog intramedullary nailing ntawm tibia. Txawm hais tias tsis sib haum xeeb cov ntaub ntawv hais txog kev sib raug zoo ntawm kev ua tsis zoo thiab kev soj ntsuam thiab cov txiaj ntsig tau pom, peb hais tias cov kws phais yuav tsum siv zog ua kom tiav qhov kev sib haum xeeb ntawm cov pob txha kom tswj tau qhov sib txawv no thiab tau txais txiaj ntsig zoo.

五. Xaus

Static locking nthuav dav medullary intramedullary nailing tseem yog tus qauv kev kho mob rau kev tshem tawm tibial qia pob txha. Lub ntsiab lus nkag raug tseem yog ib feem tseem ceeb ntawm txoj kev phais. Txoj kev suprapatellar txoj hauv kev nyob rau hauv txoj haujlwm ib nrab txuas ntxiv yog suav tias yog txheej txheem kev nyab xeeb thiab muaj txiaj ntsig, thiab cov kev tshawb fawb yav tom ntej yuav tsum tau soj ntsuam ntxiv txog qhov txaus ntshai thiab cov txiaj ntsig ntawm cov txheej txheem no. Tus kws phais neeg tuaj koom yuav tsum paub txog cov txheej txheem hloov kho tshiab niaj hnub no. Yog tias qhov kev sib haum xeeb ntawm lub cev tsis tuaj yeem ua tiav los ntawm kev kaw, cov txheej txheem kev txo qis yuav tsum tau txiav txim siab. Kev kho zoo ntawm ntau dua 90% tuaj yeem ua tiav nrog ob qho tib si nthuav dav thiab tsis nthuav dav intramedullary nailing. Txawm hais tias tus nqi kho tau zoo, cov neeg mob tseem muaj kev txwv kev ua haujlwm ntev. Hauv particular, qhov mob prepatellar tseem yog ib qho kev tsis txaus siab tom qab tibial intramedullary nailing. Tsis tas li ntawd, malrotation tom qab sab hauv tibial fixation tseem yog ib qho teeb meem tshwm sim.

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