Enkola y’okunyweza emisumaali mu tibial Intramedullary

Okunyweza emisumaali mu misuwa (intramedullary nail fixation) kusigala nga bwe bujjanjabi obusinga okukozesebwa ku kumenya ekikolo ky’ekisambi ekitali kinywevu era ekisenguddwa mu bantu abakulu. Ekigendererwa ky’obujjanjabi obw’okulongoosa kwe kuzzaawo obuwanvu, okukwatagana n’okukyukakyuka kw’ekisambi n’okutuuka ku kuwona kw’okumenya. Ebirungi ebiri mu kukuba emisumaali mu nnyindo (intramedullary nailing) kwe kufuna obuvune obutono mu kulongoosa n’okukuuma obulungi omusaayi ogugenda mu kifo we bamenyese. Okugatta ku ekyo, okusiba emisumaali mu kisambi mu nnyindo kiwa okutebenkera okutuufu okw’okumenya kw’ebiramu era kikola ng’ekyuma ekigabana emigugu ekisobozesa okukungaanya amangu oluvannyuma lw’okulongoosebwa. Enkulaakulana mu nteekateeka y’okukola emisumaali mu misuwa n’obukodyo bw’okukendeeza egaziyizza ebiraga okunyweza emisumaali mu misuwa okuli okumenya ekisambi eky’okumpi n’okumenya okw’okusatu okw’omu makkati okwa wansi.

N’okutuusa kati, closed reduction intramedullary nail fixation of tibial fractures efuuse enkola eya bulijjo eri abasawo abalongoosa amagumba abafunye obuvune. Wadde nga enkola y’okunyweza emisumaali mu mubiri (intramedullary nail fixation) emanyiddwa nnyo olw’okumenya ekikolo ky’omugongo (displaced tibial stem fractures), kikyalina okusoomoozebwa era kirina ebizibu ebingi ebiyinza okuvaamu. Obukodyo bw’okulongoosa bukyagenda mu maaso n’okukulaakulana. Ekigendererwa ky’ekiwandiiko kino kwe kunnyonnyola endowooza eziriwo kati mu kunyweza emisumaali mu misuwa egy’okumenya ekikolo ky’omugongo n’okufunza enkulaakulana eyaakakolebwa mu mulimu guno.

一. Okusooka okwekenneenya n’okukebera

Mu balwadde abato, okumenya ekikolo ky’ekisambi kitera kuva ku buvune obw’amaanyi amangi, era abalwadde balina okwekebejjebwa okulaba oba balina obuvune obukwatagana nabyo okusinziira ku ndagiriro ya Advanced Trauma Life Support (ATLS). Weekenneenye obuvune bw’olususu n’ebitundu ebigonvu ebikwetoolodde ng’okumenya ebizimba, okunyiga olususu, okwokya, ecchymosis, oba okulinnya kw’olususu; okunnyonnyola oba okumenya kuggule, era bwe kiba bwe kityo jjanjabe n’eddagala lya tetanus n’eddagala eritta obuwuka; era n’okukebera emisuwa gy’obusimu mu bujjuvu era n’okuwandiika ebyo waggulu. Weekenneenye okubeerawo kw’obulwadde bw’amagumba (osteofascial compartment syndrome) era okole okukeberebwa okw’obujjanjabi okuwerako mu balwadde bano.

Okunoonyereza okwakakolebwa kulaga nti omuwendo gw’obulwadde bw’amagumba (osteofascial compartment syndrome) oluvannyuma lw’okumenya amagumba (tibial tuberosity fractures) guyinza okuba nga guli waggulu nga 11.5 %. Okusingira ddala, ebibinja by’abalwadde abato bitera okulwala obulwadde bwa osteofascial compartment syndrome. Okuzuula obulwadde bw’ekitundu ky’amagumba (osteofascial compartment syndrome) kulina okusinziira ku bizuuliddwa mu bujjanjabi, omuli obulumi obw’amaanyi, enkyukakyuka mu misuwa gy’obusimu, okuzimba ekisenge ky’emisuwa gy’amagumba, n’okweyongera obulumi okuva mu kugaziwa kw’ebigere nga tekukola. N’olwekyo, obulwadde bw’ekitundu ky’amagumba (osteofascial compartment syndrome) busigala nga buzuuliddwa mu bujjanjabi era okuwandiika mu bujjuvu okukeberebwa mu bujjanjabi kyetaagisa. Puleesa munda mu kisenge ky’omubiri (myofascial compartment) esobola okupimibwa nga tukozesa empiso ya puleesa (Ekifaananyi 1) ng’enkola ey’okukebera ejjuliza ekigezo eky’enjawulo.

Ekifaananyi 1. Okupima puleesa mu kisenge ky’amagumba wakati nga tukozesa empiso ya puleesa

Okusobola okufuna data eyesigika, puleesa z’omu nnyindo zirina okupimibwa mu bitundu bina eby’omu nnyindo ne mu bifo eby’enjawulo munda mu buli kitundu ky’omugongo. Okunoonyereza mu biwandiiko kulaga nti enjawulo ya puleesa eri wansi wa mmHg 30 (diastolic pressure minus fascial compartment pressure) eraga nti fascial compartment syndrome. Puleesa ya diastolic etera okukendeera nga balongoosebwa, era pressure ya diastolic nga tebannaba kulongoosebwa erina okutunuulirwa nga babala puleesa ey’enjawulo.

Okunoonyereza okwakakolebwa kulaga nti okulondoola puleesa y’omu lubuto (intrafascial pressure monitoring) kye kimu ku biyinza okuba eby’omugaso mu kuzuula obulwadde bwa acute fascial compartment syndrome, nga buwulize bwa bitundu 94 % ate nga bukwata ku bitundu 98 %. Naye, okusinziira ku biyinza okusaanyaawo ebiva mu bulwadde bw’ekisenge, okuzuula obulwadde bw’ekisenge kulina okusinziira ku bizuuliddwa mu bujjanjabi, era okupima puleesa y’ekisenge wakati w’amagumba kulina okukozesebwa mu mbeera ez’enjawulo, gamba ng’omulwadde bw’alumizibwa oba ng’ebifo ebikwata ku bujjanjabi tebitegeerekeka bulungi.

Okwekenenya ebifaananyi kulina okubeeramu orthopantomograms eza bulijjo n’okulaba okw’ebbali okw’ekisambi ekifunye obuvune n’ebifaananyi eby’oku mabbali eby’ennyondo z’okugulu n’enkizi eziriraanyewo, eby’ongera okwekenneenya nga bakozesa computed tomography (CT). Mu ngeri y’emu, CT scan y’enkizi eyinza okwetaagisa okulaba layini z’okumenya ezituuka ku tibial plateau n’obuvune obukwatagana n’enkizi obutakwatagana

二. Emitego egy’obujjanjabi

Ebitundu ebinene eby’okumenyeka kw’ekitundu eky’okusatu eky’omu makkati ekya wansi eky’ekisambi nga waliwo okumenya enkizi bibadde bimanyiddwa. Nga tukozesa CT scan eza bulijjo, ebitundu 43 % eby’okumenya ekitundu eky’okusatu eky’omu makkati n’ekya wansi eky’ekisambi byawerekerwako okumenya enkizi, ng’okusinga kwetaaga okulongoosebwa. Ekika ky’okumenya ekisinga okumanyibwa kyali kya kumenya mu ngeri ya spiral ey’ekitundu eky’okusatu eky’omu makkati ekya wansi eky’ekisambi eky’ewala ekikwatagana n’okumenya kw’enkizi okw’emabega okusengulwa katono oba okutasengulwa (Ekifaananyi 2). Olw’okusengulwa okutono okw’okumenya enkizi okukwatagana, ebitundu 45 % byokka eby’obuvune bye bisobola okuzuulibwa ku bifaananyi eby’enkizi ebya bulijjo. N’olwekyo, CT scans eza bulijjo ez’enkizi zirina okussibwako essira ennyo nga waliwo okukutuka kw’ekisambi ekya wansi ekya wakati (Fig. 3).

Ekifaananyi 2.AF Okumenya mu ngeri ey’ekika kya ‘spiral fracture’ y’ekitundu eky’okusatu eky’omu makkati ekya wansi eky’ekisambi ekya ddyo (A, B) Ebifaananyi eby’oku leediyo eby’enkizi nga tebinnalongoosebwa biraga nti bya bulijjo (C). Intraoperative C-arm fluoroscopy eraga okumenya okutali kwa kusengulwa kw’enkizi ey’emabega (D) Ebifaananyi ebikubiddwa oluvannyuma lw’okulongoosebwa oluvannyuma lw’okunyweza (EF) biraga okuwona okulungi okw’okumenya kw’enkizi n’enkizi

Ekifaananyi 3. AF Okumenya okw’ekika kya ‘spiral fracture’ okw’ekitundu eky’okusatu eky’omu makkati n’ekya wansi eky’ekisambi ekya kkono (AB) preoperative radiographs; (CD) CT scans nga tebannalongoosebwa nga ziraga okumenya kw’amagulu okw’emabega okutali kwa kusengulwa; (EF) eraga okuwona awatali kubaawo mu kifuba n’okumenya kw’amagulu

三 . Enkola z’okulongoosa

01. Ekifo ekiyingira mu mpiso ya Tibial

Okuteekawo ekifo ekituufu eky’okuyingira kikola kinene nnyo era okunoonyereza kungi mu biwandiiko kuwadde amawulire amakulu ku kifo ky’omubiri eky’ekifo ekituufu eky’okuyingira eky’okukuba emisumaali mu misuwa gy’okumenya kw’amagulu. Okunoonyereza kuno kulaga nti ekifo ekituufu eky’okusibiramu kisangibwa ku mabbali g’omu maaso ag’ekisenge ky’omugongo (tibial plateau) era nga kiri wakati ddala ku kitundu ky’ekisambi eky’ebbali. Ekitundu eky’obukuumi nga kirimu obugazi bwa mm 22.9 ± mm 8.9, ekitakola kwonooneka ku bizimbe by’ebiyungo ebiriraanyewo, nakyo kyaloopebwa. Mu nnono, entandikwa y’okunyweza emisumaali mu misuwa egy’okumenya ekikolo ky’ekisambi ebadde eteekebwawo okuyita mu nkola ya infrapatellar, oba nga twawula omusuwa gw’omugongo (enkola ya transpatellar) oba nga baggyamu ekitundu ky’omusuwa gw’omugongo oguyimirira (enkola ya paratendinous).

Semi-extension intramedullary nailing esikiriza nnyo mu biwandiiko by’amagumba ebisembyeyo, era Tornetta ne Collins bawa amagezi okukozesa enkola ya medial parapatellar okunyweza munda kw’omusumaali mu mbeera ya semi-extension okwewala okufuluma kw’entikko y’omusumaali mu misuwa mu anterior tibial cortex.3 The use of a medial parapatellar approach for okusiba emisumaali mu misuwa mu mbeera ya semi-extension nakyo kirungi. Okukozesa enkola ya suprapatellar okukuba emisumaali mu tibial intramedullary n’okuyingiza omusumaali ogw’omu kifuba okuyita mu kiyungo kya patellofemoral mu mbeera ya semi-extended kirungi.

Enkola eno ekolebwa ng’okugulu kufukamidde ku diguli nga 15-20, era okusala okuwanvu okwa sentimita nga 3 kukolebwa obugazi bw’engalo nga emu oba bbiri waggulu w’olususu. Omusuwa gwa quadriceps gwawulwamu mu ngeri ya longitudinal era blunt dissection ekolebwa mu kinywa kya patellofemoral. Socket enzirugavu eyingizibwa okuyita mu kinywa ky’omugongo (patellofemoral joint) okukola ekifo ekiyingira ku nkulungo y’ekitundu ky’omugongo ekiyitibwa proximal anterior tibial cortex ne articular surface (Figure 4).

Ekifaananyi 4. ab Ebifaananyi eby’okulongoosebwa nga (a) okwawula omusuwa gw’omugongo ogw’ennya n’okuyingiza trocar okuyita mu kiyungo kya patellofemoral okutuuka mu kifo ekiyingira mu tibial; (b) okulaba okw’ebbali mu kulongoosa ekifo we bayingira

Ekintu ekisima ekya mm 3.2 kikozesebwa okuzuula ekifo empiso w’etandikira wansi w’obulagirizi bwa C-arm. Socket eriko ebituli eweereddwayo okulongoosa obulungi ebifo ebiyingira n’okufuluma. Emitendera gy’okulongoosa egisigadde omuli reaming n’okuyingiza omusumaali mu tibial gikolebwa nga giyita mu socket.

EBIRUNGI EBIYINZA: Enfo y’amagulu agagaziyiziddwa ekitundu eyinza okuyamba mu kuddamu okuteeka amagulu mu kifo ky’okumenya naddala mu kumenya nga kuliko ekitundu kya kusatu eky’okumpi ekya bulijjo eky’ekisambi era nga kiri mu nkoona mu maaso. , Enfo egaziyiziddwa ekitundu eyinza okumalawo okusika omuguwa ku binywa by’omugongo ogw’ennya n’okuyamba mu kuddamu okuteeka mu kifo ky’okumenya. , Enkola ya semi-extended position suprapatellar nayo eyinza okuba eky’okuddako mu nkola ey’ekinnansi ey’okubeera wansi w’amaaso (Figure 5).

Ekifaananyi 5. Ekifaananyi mu kulongoosebwa ekiraga obuvune bw’ebitundu ebigonvu mu kitundu ky’omugongo ng’ekiraga enkola ey’okungulu mu kifo ekigaziyiziddwa ekitundu.

Okunoonyereza kulaga nti enkola ya suprapatellar ey’okukuba emisumaali mu tibial intramedullary mu mbeera ya semi-extended nkola ya kulongoosa etali ya bulabe era ekola bulungi. Okugezesebwa okw’obujjanjabi mu biseera eby’omu maaso kwetaagibwa okwongera okunoonyereza ku birungi n’ebibi ebiri mu nkola ya suprapatellar approach intramedullary nailing n’okwekenneenya ebivaamu eby’ekiseera ekiwanvu ebikwatagana n’enkola eno.

02. Okuzzaawo tekinologiya

Okuteeka omusumaali ogw’omu kifuba (tibial intramedullary nail) gwokka tekivaamu kukendeeza kumenya kimala; okukendeeza ku kumenya okutuufu kulina okukuumibwa mu nkola yonna ey’okusiba n’okuteeka emisumaali mu misuwa. Okukozesa okusika kw’omu ngalo kwokka kuyinza obutatuuka bulijjo kukendeeza ku kumenya kw’omubiri (anatomic reduction) kwennyini. Ekitundu kino kijja kunnyonnyola enkola ez’enjawulo ez’okukendeeza ku kuggalawo, ezitayingirira nnyo, n’ez’okuggulawo.

-Obukodyo bw'obukodyo bw'okuzzaawo obuggadde

Enkola z’okukendeeza eziggaddwa zisobola okutuukirira n’ekintu ekikendeeza nga F-fracture reducer, ekyuma ekikendeeza ekitambuzibwa mu ngeri ya F-shaped radiographically etereeza enkoona z’okukyusakyusa/okufulumya awamu n’okuvvuunula wakati/ebbali (Fig. 6).

Ekifaananyi 6. Ekikendeeza okumenya mu ngeri ya F ekijuliziddwa mu kulongoosa

Kyokka, ekyuma kino kisobola okuteeka situleesi ey’amaanyi ku bitundu ebigonvu, era okukozesa ekyuma kino eky’okuzzaawo okumala ebbanga eddene kisaana okwewalibwa. Reduction forceps nazo zisobola okuteekebwa mu lususu, nga bwe kiri mu mbeera y’okumenya kwa spiral ne oblique. Ebikozesebwa bino bisobola okusiigibwa mu ngeri ey’omukwano eri ebitundu ebigonvu nga biyita mu bitundu ebitonotono (Figure 7).

Ekifaananyi 7. Okusiba mu lususu okuddamu okuteekawo okumenya kw’ekisambi

Ekika kya clamp n’ekifo we basala okulongoosebwa birina okulondebwa okusinziira ku nkola ey’okukendeeza ku kwonooneka kw’ebitundu ebigonvu okumala ebbanga eddene okuva mu kuteekebwa kwa clamp (Figure 8).

Ekif

Retractors nazo kye kimu ku bikozesebwa ebitera okukozesebwa okuzzaawo obuwanvu mu tibia. Zitera okuteekebwa wakati ne wala okuva mu kifo omusumaali ogw’omu lubuto we gwetaaga okuteekebwa. Ppini ezisika eziriraanye zisobola okuteekebwa okukoppa ekifo kya sikulaapu eziyiza okumpi, ekisobozesa okukendeeza amangu okumenya ng’omusumaali ogw’omu lubuto guyingidde.

Mu mbeera ezimu, obukodyo bw’okukendeeza obuggadde n’obutayingirira nnyo bukyali tebumala kufuna kukendeeza ku mubiri. Mu mbeera ng’ezo, obukodyo bw’okukendeeza ku kutema busaana okulowoozebwako n’okuddukanya n’obwegendereza ebitundu ebigonvu ebibyetoolodde. Ebizibu ebiyinza okubaawo mu bukodyo bw’okukendeeza ku kulongoosa mu ngeri ey’olubeerera mulimu okulumwa ennyo mu kulongoosa, ekiyinza okwongera ku bulabe bw’okukwatibwa obulwadde mu kifo we balongoosezza. Okugatta ku ekyo, okwongera okuggyamu omusaayi ogugenda mu kifo we bamenyese kiyinza okwongera ku bulabe bw’okumenya obutakwatagana oluvannyuma lw’okulongoosebwa.

-Obukugu mu by'ekikugu mu kutema n'okuzzaawo ekifo

Enkola z’okukendeeza ku kutema tezikkiriza bipimo bya kulongoosa byokka ebiteekebwa mu kifo ekituufu, naye n’okusiiga obuguwa obutono oba obutonotono mu kifo we bamenyese okukuuma okukendeeza ku kumenya mu biseera by’okusiba emisumaali mu nnyindo.

Puleti zinywezebwa ku bitundutundu by’okumenya okw’okumpi n’okw’ewala nga tukozesa sikulaapu za monocortical. Omusumaali gukuumibwa mu nkola yonna ey’okusiba n’okuteeka omusumaali ogw’omu kifuba mu kisambi. Oluvannyuma lw’okuteeka omusumaali ogw’omu lubuto, ebbakuli yaggyibwawo oba okulekebwa mu kifo kyayo okutumbula obutebenkevu bw’ekizimbe ekinywevu (Ekifaananyi 9). Nga oleka epulati mu kifo, sikulaapu y’omugongo emu erina okukyusibwamu ne sikulaapu y’omugongo ogw’emirundi ebiri. Kisaanye okulowoozebwako okukozesebwa mu mbeera ezirondeddwamu ng’ekikolo ky’ekisambi kyetaaga okulongoosebwa mu lwatu okusobola okutuuka ku kukendeeza ku kumenya okukkirizibwa.

Ekifaananyi 9. Okumenyeka kw’ekisambi ekiggule nga kuliko okukendeera okw’amaanyi n’okukosebwa kw’amagumba, okunyweza ekitundu ekimu eky’omubiri (single cortical fixation) nga kiriko akaguwa akatono ku nkomerero y’okumenya okwamenyese oluvannyuma lw’okukendeeza n’okuggyawo akaguwa oluvannyuma lw’okunyweza omusumaali mu lubuto

Ekigendererwa ky’omusumaali oguzibira kwe kufunza ekituli ky’omubiri (medullary cavity) mu kitundu kya metaphyseal. Emisumaali egizibira giteekebwa munda mu kitundu ekimpi eky’ennyindo ne ku ludda olukonvu olw’obulema nga tebannaba kuteekebwa mu misumaali mu misuwa. Okugeza, obulema obumanyiddwa obw’okumenya kw’ekitundu eky’okusatu eky’okumpi eky’ekisambi (proximal third of the tibia) bumanyiddwa nga valgus ne forward angulation. Okutereeza obulema bwa valgus, sikulaapu esiba esobola okuteekebwa mu kitundu eky’ebbali eky’ekitundu ky’okumenya okw’okumpi (kwe kugamba, oludda olukonvu olw’obulema) mu ludda olw’omu maaso n’emabega. Omusumaali ogw’omu lubuto gulung’amibwa okuva ku ludda olw’omu makkati, bwe kityo ne kiziyiza valgus. Mu ngeri y’emu, obulema bw’enkoona busobola okuvvuunukibwa nga oteeka sikulaapu ey’okusiba wakati okutuuka ku mabbali ku kitundu eky’emabega ekya bulooka ey’okumpi (kwe kugamba, oludda olukonvu olw’obulema) (Ekifaananyi 10).

Ekifaananyi 10. assisted reset of tibial fracture nga bateeka emisumaali egizibira

-Okugaziwa kw’ebitundu by’omubiri (medullary expansion).

Oluvannyuma lw’okumaliriza okuddamu okuteeka mu kifo ky’okumenya, medullary reaming elondebwa okuteekateeka eggumba okuyingiza omusumaali mu medullary. Waya ekwata ku mupiira eyingizibwa mu kisenge ky’obusimu bw’omugongo (tibial marrow cavity) n’eyita mu kifo we yamenyeka, era ekyuma ekikuba ebyuma (reaming drill) kiyisibwa ku waya ekwata ku mupiira. Ekifo kya waya ekwata ku mupiira kyakakasibwa wansi wa C-arm fluoroscopy nti kiri ku ddaala ly’ekiyungo ky’enkizi, era waya elungamya yali wakati bulungi ku kulaba kwombi okw’omu maaso n’emabega (Figure 11).

Ekifaananyi 11. kiraga ekifo kya guidewire mu medullary cavity ku C-arm fluoroscopy mu bifo eby’omu maaso n’eby’ebbali

Ensonga ya expanded versus non expanded medulla ebaddemu okusika omuguwa. Tulowooza nti abasawo abasinga obungi abalongoosa mu North America baagala nnyo okusiba emisumaali mu kisambi mu misuwa egy’okugaziya okusinga egitagaziyiziddwa. Naye, okukuba emisumaali mu misuwa gyombi egyagaziyiziddwa n’egitali gigaziyiziddwa kuyinza okukozesebwa ng’obukodyo obw’omutindo obukkirizibwa, era ebirungi bisobola okufunibwa n’enkola zombi.

-Okusiba sikulaapu okuteeka

Okukozesa sikulaapu ezikwatagana mu kumenya ekikolo ky’ekisambi kigendereddwamu okuziyiza okufunza n’okutambula obubi, okugaziya ebiraga okukuba emisumaali mu kisambi mu kisambi okutuuka ku kumenya ekikolo ky’ekisambi eky’okumpi n’eky’ewala ekizingiramu metaphysis. Mu kumenya okuzingiramu ekitundu kya metaphyseal, sikulaapu ezikwatagana zaafuuka kikulu nnyo mu kukuuma okukwatagana kw’ekyekulungirivu.

Sikulufu ssatu ezikwatagana okumpi zalongoosa nnyo okutebenkera, era sikulaapu ezikwatagana ezitebenkedde mu nkoona ziyinza okuwa obutebenkevu obusinga ku sikulaapu eza bulijjo ezisiba, ekiyinza okusobozesa okutebenkera kw’enzimba y’emu okufunibwa n’omuwendo omutono ogwa sikulaapu ezisiba. Ebiwandiiko ebikwata ku bujjanjabi ku muwendo n’ensengeka ya sikulaapu ezisiba ezeetaagisa okunyweza munda mu kifuba (tibia) bisigala nga bitono.

Okuteeka sikulaapu ezikwatagana okumpi (proximal interlocking screws) kitera okukolebwa nga tukozesa sikopu eyungiddwa ku 'intramedullary nail spike'. Distal interlocking screws ziyingizibwa freehand wansi w’obulagirizi bwa fluoroscopic. Okukozesa enkola y’okulungamya eyambibwako kompyuta ey’amasannyalaze kirungi okuyingiza sikulaapu ezikwatagana n’ekisambi eky’ewala (Ekifaananyi 12). Enkola eno ekkiriza okuyingiza sikulaapu ezikwatagana ewala nga tewali butangaavu era eragiddwa okuba enkola esoboka era entuufu.

Ekifaananyi 12.AB Okusiba sikulaapu nga tuyita mu ndowooza ya C-arm; Sikulufu z’okusiba CD nga ziyita mu kusiba nga kuyambibwako kompyuta ey’amasannyalaze

Okuteeka sikulaapu ezikwatagana okumpi n’ewala (proximal and distal interlocking screws) nkola ya kulongoosa etali ya bulabe era sikulaapu ezikwatagana zirina okuteekebwa mu ngeri entuufu era ekwatagana n’ebitundu ebigonvu.

Okunoonyereza ku anatomic kulaga nti wakyaliwo akabi k’okusannyalala kw’obusimu obuyitibwa peroneal nerve palsy nga oteeka proximal medial to lateral oblique interlocking screws. Okukendeeza ku bulabe buno, abasawo abalongoosa balina okulowooza ku kusima sikulaapu wansi w’obulagirizi bw’omukono gwa C, nga enkoona ya fluoroscopic ey’omukono gwa C yeesimbye ku nnyonyi y’ekintu ekisima. Okuyingira kwa drill mu cortex y'ekisambi eky'ewala kuyinza okuba okuzibu okutegeera nga tuyita mu kukwata, era okumpi n'omutwe gw'ennyindo kuyinza okuzibikira endowooza y'okukwata n'okuwa omusawo alongoosa endowooza nti eri 'mu ggumba' so nga mu butuufu omutwe gw'ennyindo guyingiziddwa. Obuwanvu bwa sikulaapu tebulina kusalibwawo na kusima kwokka okwa graduated drill wabula n’okupima obuziba obutuufu. Okupima kwonna obuwanvu bwa drill oba screw obusukka mm 60 kulina okuleeta okuteebereza nti posterolateral protrusion, ekiyinza okuteeka common peroneal nerve mu bulabe bw’okulumwa.

Sikulufu ezikwatagana ez’ewala ez’omu maaso n’ez’emabega ziteekebwa nga zifaayo ku kukuuma ekibinja ky’emisuwa gy’emisuwa egy’omu maaso, tibialis anterior tendon, ne extensor digitorum longus. Wadde ng’okuteeka sikulaapu mu lususu ebiseera ebisinga tekiba kya bulabe, abasawo abalongoosa balina okumanya akabi akali mu nsengekera z’ebitundu ebigonvu ebiriraanyewo. Ku kumenya ekikolo ky’omugongo ekisinga obungi, sikulaapu bbiri ez’okumpi n’ebiri ez’ewala ezikwatagana ziwa obutebenkevu obumala. Okumenya kw’ekisambi okw’okumpi n’okw’ewala kuyinza okuganyulwa mu kuteeka sikulaapu endala ezikwatagana mu nnyonyi ez’enjawulo okwongera okutebenkera kw’ensengekera eno (Ekifaananyi 13).

Ekifaananyi 13. Okumenyeka kw’ekisambi okungi, okujjanjabwa n’okusiba emisumaali mu kisambi nga bakozesa sikulaapu bbiri ez’ewala n’essatu ezikwatagana, nga x-ray eziddirira ziraga nti okumenya kwawona.

-Okunyweza Fibular

Dizayini z’emisumaali egy’omulembe egy’omu kifuba nga zirina sikulaapu ezikwatagana ewala zigaziyizza ebiraga okukuba emisumaali mu kisambi mu misuwa okuzingiramu okumenya okw’okumpi n’okw’ewala okuzingiramu ekitundu kya metaphyseal.

Ensengeka za sikulaapu ez’enjawulo ezikwatagana ewala zaakozesebwa mu kunoonyereza (sikuluku 2 okuva mu makkati okutuuka ku bbali okusinziira ku sikulaapu 2 eziteekeddwa nga zeesimbye ku ndala n’omugatte gwa sikulaapu 3 ezikwatagana ewala okusinziira ku sikulaapu 1 yokka ekwatagana n’ewala). Mu balwadde abaakolebwako fibular fixation ne tibial intramedullary nail fixation, omuwendo gw’okubulwa reset gwali wansi nnyo. Omugatte gwa 13 % ku balwadde abalina okunyweza emisumaali mu misuwa nga tebalina fibular fixation baalaga okufiirwa postoperative of reset, bw’ogeraageranya n’abalwadde 4 % abalina tibial nail fixation nga tebalina fibular fixation.

Mu kugezesebwa okulala okugeraageranya obulungi bw’okunyweza emisumaali mu tibial intramedullary okusinziira ku fibular fixation ne tibial intramedullary nail fixation okusinziira ku butanyweza fibular fixation, abalwadde abajjanjabwa n’okunyweza fibular fixation nga bagasseeko n’okusiba emisumaali mu tibial baalaga okulongoosa mu rotational ne inversion/eversion alignment.

Tumaliriza nti adjunctive fibular fixation etuukiriza era ekuuma okukendeeza ku kumenya kw’amagulu mu kumenya kw’amagulu okw’ewala ekitundu kimu kya kusatu nga bayita mu kunyweza emisumaali mu misuwa. Wabula ekizibu ky’ebizibu by’ebiwundu okuva mu kutema okulala mu kitundu ky’ebitundu ebifunye obuvune kikyaliwo. N’olwekyo tusaba okwegendereza mu kukozesa enkola ya assisted fibular fixation.

03. Ebivuddemu

Intramedullary nailing fixation of tibial stem fractures kiyinza okuvaamu ebirungi. Emiwendo gy’okuwona kw’okusiba emisumaali mu kisambi mu misuwa gibadde giwandiikiddwa mu kunoonyereza okw’enjawulo. Nga tukozesa ebintu eby’omulembe ebiteekebwa mu mubiri n’obukodyo obutuufu obw’okulongoosa, emiwendo gy’okuwona gisuubirwa okusukka ebitundu 90 %. Omutindo gw’okuwona kw’okumenya ekikolo ky’omugongo ogwalemererwa okuwona oluvannyuma lw’okunyweza omusumaali mu misuwa gwalongoosebwa nnyo oluvannyuma lw’okunyweza munda n’omusumaali ogw’okubiri ogwagaziyizibwa mu musuwa.

Okukebera ebivaamu ku mwaka gumu oluvannyuma lw’okulongoosebwa kwalaga nti okutuuka ku 44 % ku balwadde baasigala nga balina obuzibu mu kukola mu kitundu ekya wansi ekyalumizibwa, era okutuuka ku 47 % baagenda mu maaso n’okuloopa obulemu obukwatagana n’emirimu ku mwaka gumu oluvannyuma lw’okulongoosebwa. Okunoonyereza kuno kulaga nti abalwadde abajjanjabwa n’okusiba emisumaali mu kifuba (intramedullary nailing of the tibia) bakyagenda mu maaso n’obuzibu obw’amaanyi mu nkola y’emirimu mu bbanga eggwanvu. Abasawo abalongoosa balina okumanya ensonga zino era bawe abalwadde amagezi okusinziira ku nsonga zino!

四. Ebizibu ebiva mu kulongoosebwa

01. Obulumi nga tebunnatuuka mu bitundu by’omubiri

Obulumi mu maaso g’omugongo (anterior patellofemoral pain) kizibu ekitera okubaawo oluvannyuma lw’okunyweza omusumaali mu misuwa (intramedullary nail fixation) mu kumenya ekikolo ky’ekisambi. Okunoonyereza kulaga nti abalwadde nga 47 % oluvannyuma lw’okukuba emisumaali mu misuwa bayinza okufuna obulumi obw’omu lubuto (prepatellar pain), ekivaako obutategeerekeka bulungi. Ensonga eziyinza okukwata ku bisambi ziyinza okuli obuvune obuva ku buvune n’obujjanjabi ku nsengekera z’omu bitundu by’omubiri, obuvune ku ttabi ly’obusimu obuyitibwa infrapatellar branch of the saphenous nerve, obunafu bw’ebinywa by’ekisambi eky’okubiri olw’okunyigirizibwa kw’obusimu obuyitibwa neuromuscular reflexes obukwatagana n’obulumi, fibrosis of the fat pad leading to impingement, reactive patellar tendonitis, bending strain from intramedullary okusiba emisumaali ku kitundu eky’okumpi eky’ekisambi, n’okufuluma kw’enkomerero y’omusumaali ey’okumpi.

Nga basoma etiology of prepatellar pain after intramedullary nailing, enkola ya transpatellar tendon yageraageranyizibwa ku nkola ya parapatellar. Enkola ya transpatellar tendon eyinza okuba nga ekwatagana n’okulumwa okugulu okungi oluvannyuma lw’okulongoosebwa. Wabula, prospective randomized clinical data teyalaze njawulo nnene wakati w’enkola ya transpatellar tendon n’enkola ya parapatellar.

Obulung’amu bw’okuggyawo okulonda okunyweza munda okukola ku bulumi bwa prepatellar oluvannyuma lw’okukuba emisumaali mu tibial intramedullary tebukakafu. Tukuwa amagezi nti okuggyawo omusumaali gw’omu kifuba ogw’omu kifuba (intramedullary tibial nail) kulowoozebweko singa ekivaako eky’ebyuma kisobola okuzuulibwa, gamba ng’okufuluma kw’omusumaali oba sikulaapu efuluma ekwatagana. Wabula omugaso gw’okuggya emisumaali mu tibial intramedullary mu balwadde abalina obubonero gukyalina okubuusibwabuusibwa.

Ku bikwata ku bulumi bwa prepatellar oluvannyuma lw’okulongoosebwa, ekivaako obulumi tekyasobola kulagibwa bulungi mu kunoonyereza okwasooka okw’obujjanjabi okw’okunyweza omusumaali mu misuwa egy’omumwa gwa tibial ku patella mu mbeera eya semi-extended. Nolwekyo, okunoonyereza okunene okw’obujjanjabi n’okugoberera okw’ekiseera ekiwanvu kwetaagisa okukakasa ekikolwa ky’okunyweza emisumaali mu misuwa mu nkola ya suprapatellar ku bulumi bwa prepatellar oluvannyuma lw’okulongoosebwa.

02.Okukwatagana obubi oluvannyuma lw’okulongoosebwa

Obulwadde bw’amagumba oluvannyuma lw’okukosebwa bukyali kizibu kinene oluvannyuma lw’okujjanjaba okukutuka kw’ekikolo ky’ekisambi nga bakozesa emisumaali mu misuwa. Okunoonyereza ku biomechanical kulaga nti tibial malalignment eyinza okuvaamu enkyukakyuka ennene mu contact pressures ku binywa by’enkizi n’okugulu ebiriraanyewo.

Okunoonyereza okw’obujjanjabi okwekenneenya ebiva mu bujjanjabi n’okukuba ebifaananyi eby’ekiseera ekiwanvu oluvannyuma lw’okumenya ekikolo ky’ekisambi kuwadde ebikwata ku bikontana ku biva mu kulemererwa kw’ekisambi, nga tewali kimaliriziddwa kitegeerekeka n’okutuusa kati.

Lipoota z’obutakwatagana bulungi oluvannyuma lw’okulongoosebwa oluvannyuma lw’okukuba emisumaali mu kisambi mu misuwa (intramedullary nailing of the tibia) zisigala nga ntono, ng’abalwadde batono be baloopebwa. Okukyusakyusa obubi oluvannyuma lw’okulongoosebwa kukyali kizibu kya bulijjo mu kukuba emisumaali mu tibial intramedullary, era okwekenneenya okukyusakyusa tibial mu kulongoosebwa kukyali kusoomoozebwa. N’okutuusa kati, tewali nkola ya bujjanjabi oba okukuba ebifaananyi etandikiddwawo ng’omutindo gwa zaabu ogw’okusalawo okukyusakyusa ekisambi mu kulongoosebwa. Okusingira ddala, obulema mu kuzimbulukuka okw’ebweru bulabika nga butera okubaawo okusinga obulema mu kuzimbulukuka okw’omunda. Okukebera mu malwaliro okwekenneenya okukyusakyusa obubi oluvannyuma lw’okulongoosebwa kwaloopebwa nti si kutuufu era kwalaga enkolagana entono n’okukebera CT.

Tulowooza nti obutakwatagana busigala nga kizibu kya bbanga ddene mu kumenya ekikolo ky’ekisambi ekijjanjabwa n’okukuba emisumaali mu kisambi mu misuwa. Wadde nga waliwo data ezikontana ku nkolagana wakati w’obutakwatagana n’ebiva mu bujjanjabi n’okukuba ebifaananyi, tuteesa nti abasawo abalongoosa balina okufuba okutuuka ku kukwatagana mu mubiri (anatomic alignment of fractures) okusobola okufuga enkyukakyuka eno n’okufuna ebivaamu ebisinga obulungi.

五. Mu bufunzi

Static locking expanded medullary intramedullary nailing esigala nga ye bujjanjabi obwa bulijjo eri okumenya ekikolo ky’omugongo ekisenguddwa. Ekifo ekituufu eky’okuyingira kisigala nga kitundu kikulu nnyo mu nkola y’okulongoosa. Enkola ya suprapatellar mu kifo ekigaziyiziddwa ekitundu (semi-extended position) etwalibwa ng’enkola etali ya bulabe era ekola, era okunoonyereza mu biseera eby’omu maaso kwetaaga okwongera okwekenneenya akabi n’emigaso gy’enkola eno. Omusawo alongoosa alina okuba ng’amanyi bulungi obukodyo obw’omulembe obw’okuzzaawo ekifo. Singa okukwatagana kw’okumenya kw’omubiri (anatomic fracture alignment) tekuyinza kutuukirizibwa nga tuyita mu nkola enzigale, obukodyo bw’okukendeeza ku kutema (incisional reduction techniques) busaana okulowoozebwako. Emiwendo emirungi egy’okuwona egisukka mu 90 % gisobola okutuukibwako nga bakozesa emisumaali egy’omu lubuto egyagaziyiziddwa n’egitagaziyiziddwa. Wadde nga emiwendo gy’okuwona emirungi, abalwadde bakyalina obuzibu mu mirimu egy’ekiseera ekiwanvu. Okusingira ddala, obulumi bw’omugongo (prepatellar pain) busigala nga kwemulugunya okwa bulijjo oluvannyuma lw’okukuba emisumaali mu tibial intramedullary. Okugatta ku ekyo, okutambula obubi oluvannyuma lw’okunyweza ekisambi munda (internal tibial fixation) kusigala nga kizibu kya bulijjo.

Ebiwandiiko ebikozesebwa

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8.Purnell G. J., Glass E. R., Altman D. T., Sciulli R. L., Muffly M. T., Altman G. T., ne banne. Ebivudde mu nkola ya computed tomography okwekenneenya okumenya kw’omugongo ogw’okusatu ogw’ewala okwekenneenya okumenya kw’amagulu okutali kukwatagana. J Okulumwa ennyo. 2011;71:163-168. doi: 10.1097/TA.0b013e3181edb88f.

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