Tibial fracture, suprapatellar intramedullary nail hmanga nail hman dan a ni

Tibial fracture tan intramedullary nailing technique: suprapatellar, transarticular approach hmangin khup 20-30°-a flexed leh intra-articular structures venhimna tur protective tube bik hmangin.

01.Tibial Intramedullary-a Nailing hmanga siam a ni: access leh alignment, khup hmalam na

Tibial fractures intramedullary nailing atan surgical access hi a pawimawh hle a, chu chu intramedullary nail chu entry point dik tak kal tlanga dah theih nan, intra-articular knee structures tihchhiat tlem nan leh fracture repositioning tha ber leh nail entry dik tak neih theih nan a pawimawh hle.

Tibial stem fracture atana classic approach chu median infrapatellar emaw parapatellar emaw approach a ni. Heng approach te hi mid-portion fracture tan chuan hman tur ni mahse, postoperative valgus, anterior, emaw syndesmotic deformities hi proximal fracture tam zawkah a awm fo thin.

Proximal tibial fracture-a malalignment awm chhan ber chu khup flexion laiin quadriceps tendon a pulling avanga deformity leh implant insertion laiin nail tip leh posterior tibial cortex inkara mechanical conflict vang a ni. Patella hian sagittal plane-a nail chu axial entry a veng bawk (Fig. 1a, b). Chuvangin, point chhunga luh dan tlangpui dang chu medial parapatellar incision hmangin a ni a, chu chuan medial-to-lateral nail insertion tlem a siam a ni (Figs. 1c leh 2). Nail chu fracture atanga distal intramedullary canal a luh chuan proximal portion chu exostosis ah a tilt a (Fig. 2). A tawp berah chuan anterior chamber muscle-te resting tension hian ectropion-ah hian tlem a thawhhlawk hle (Fig. 3).

Figure 1 a,b Infrapatellar approach hmanlai hmang hian patella hian nail axial entry a veng a, chu chuan anterior apical sagittal alignment leh ectropion coronal alignment common deformity a thlen thin.c Intramedullary nail alignment chu parapatellar approach hmangin an ti a.

Figure 2 Medial parapatellar incision hmanga entry point hnaih chuan medial atanga lateral nail insertion tlem a awm thin. Nail chu fracture (a) atanga distal medullary canal-a a luh rual chuan proximal portion chu flare-ah a tilt a (b) .

Fig. 3 Resting tension of the anterior muscle compartment ( a ) chuan ectopic arrangement fiah lo tak ( b ) a siam a.

Tibia chu hmun zau zawka nail hian intraoperative knee flexion na tak nena inzawm harsatna awm lo turin a pui a ni.He technique hi Gelbke, Jakma et al. kum 2010 khan a lar chho a, tun hnaiah a lar chho hle a, a chhan chu tibia chu a ke leh ke dinglam deuha nail hian fracture manipulation leh repositioning a awlsam phah a ni. Fluoroscopy hi technically chuan tih a awlsam tawh hle. Suprapatellar nailing atana fluoroscopy hun hi infrapatellar nailing aiin a rei zawk tih an sawi a ni . Chu bakah, nail insertion angle (sagittal plane-ah) chu infrapatellar nailing aiin he approach hmang hian tibia longitudinal axis nen a inmil zawk a hei hian nail tip leh posterior cortex inkara mechanical clash a veng a, chu chuan fracture tihtlem a ti awlsam hle.

Postoperative anterior knee na hi a kaihhnawih a ni. Khup hmalam natna hi ruh tliak nei zinga 50-70% velin an nei tawh a, endplate lakchhuah hnuah 30% chauhvin natna reh an nei thung. Access-related scar formation of the patellar tendon leh Hoffa’s fat pad hi operation hnua khup natna thlentu nia chhut a ni. Chu bakah, suprapatellar approach hian saphenous nerve patellar branch branch titawp tura traditional incision a pumpelh a, hei hian anterior knee numbness leh dulled sensation a veng bawk (Figure 4). Quadriceps tendon kal tlanga nail pass a, chu chuan patellar tendon chu a awm reng a, postoperative knee pain rate chu nasa takin a tihhniam niin a lang.

Fig. 4 Saphenous nerve leh tibialis obliqua nail-a access hrang hrang inzawmna

Proximal fractures atanga result tha tak a awm avangin clinical practice-a indication te chu fracture zawng zawngah pawh tihzauh a ni.

Suprapatellar approach-a intramedullary nailing chungchanga harsatna awm thei te:

- Khup ruh (knee joint) ah reaming debris a awm thei. Mahse, retrograde femoral nailing hmanga clinical experience-ah chuan hun rei lote chhung leh hun rei tak chhunga nghawng tha lo a awm lo.

- Engtin nge implant chu a ruh a dam hnuah lakchhuah a nih? Technical lamah chuan suprapatellar approach hmanga intramedullary nail lakchhuah theih ni mahse, he technique hi a harsa a, surgeon tam zawk chuan infrapatellar approach hmanga intramedullary nail lakchhuah hi an duh zawk a ni.

02.Engtikah nge suprapatellar intramedullary nail hi hman tur?

A thatna te

- Semi-extended knee position hian nail insertion laiin muscle force leh retention relaxing hmangin fracture manipulation leh reduction a ti awlsam a ni.

- Traditional technique nena khaikhin chuan proximal, segmental, leh distal fracture-a postoperative malalignment awm theihna a hniam zawk

- Nailing hi technically chuan tih a awlsam zawk

- Nailing hi 'single surgeon procedure' anga tih theih a ni.

- Fluoroscopy hun tihtlem

- Patellar tendon a chhiat loh bakah post-nailing anterior knee pain a awm tlem zawk

- Multi-team procedure-a tih awlsam zawk, polytrauma ang bawkin.

A that lohna te

- Knee cartilage leh intra-articular structure dangte tihchhiat theihna

- Khup natna vei theihna a sang

- Implant lakchhuah nan hian kawng dang a ngai mai thei

Indication te chu

- Extra-articular fractures a awm (Type AO 41A) 1. A rilru a hah lutuk chuan a rilru a buai em em a.

- Tibial diaphysis (type AO 42A-C) a ruh tliak awlsam tak takte

- Segmental tibial diaphysis tihchhiatna (type AO 42C) a ni.

- Extra-articular leh simple intra-articular distal tibia-a distal extension fracture (type AO 43A leh C1)

- Khup tui chunga awm

Contraindications te pawh a awm

- Gustilo grade 3C open fractures of the tibia chu joint infection hlauhawmna a san vang a ni a, mahse open fracture-ah chuan joint infection hlauhawmna a sang tih hmuhchhuah a la ni lo

- Soft tissue tear na tak, suprapatellar region-a contamination emaw infection emaw a awm

- Ipsilateral knee prosthesis (a danglamna awm lo) .

- Khup fusion a awm

- Khup hyperextension >20° a awm

- Ipsilateral tibial plateau fracture-a nail luhna hmun hi a awm lo

- Nail luhna tur tikhawlotu implants

- Ipsilateral patella fracture (a danglamna a awm lo) .

03. Surgery tih dan tur

1 Taksa dinhmun leh thlir dan

Fig. 5 Damlo chu radiolucent table-ah supine-in a mu a, chu chuan split-leg position a phalsak a ni. A ke ruh tliak chu zalen takin a innghat a, khup ruh (a) hnuaiah scroll dahin khup 10-30° a inher theihna tur a ni 

(b) a ni. C-arm chu a sir lehlamah dah a ni. Unaffected leg chu lateral position-a imaging dik tak neih theih nan horizontal atanga 10-30°-a tihhniam a ni.

2Needle luhna tur dik tak zawng rawh

Figure 6 Hetiang approach hi patella shaft, tibial tuberosity, leh anterior tibial cortex te hian a tarlang a ni. Sen 2 cm sei zawnga vun incision chu patella chunglam base 1-1.5 cm proximal-ah siam a ni. Quadriceps tendon chu a lang chhuak a, tendon fibers lam hawiin midline longitudinal incision siam a ni. Suprapatellar recess chu hawn a ni a, surgeon kut zungtang chu patella hnuai atang hian khup ruh chhungah a lut a, chu chuan a luh awlsam dan a teh a ni. Limb tlem a sei chuan khup (kneecap) thlenga luh a awlsam phah thei. Patella sang tlemte atan Langenbeck retractor dah hian access a tichak thei bawk. Joint space a tawi hle a, instrumentation a harsat chuan patella chu a sir khatah semi-dislocate turin medial emaw lateral support band emaw chu a bulah incised theih a ni.

3Cartilage venhimna

Figure 7 Surgery avanga hliam laka patellofemoral cartilage venhim hi surgical procedure thil tum ber pakhat a ni. Chuvangin, instrument leh nail insertion-ah hian protective sleeve hman a ngai a ni.a Transarticular access atana hmanrua te chu insertion handle, pawn lam (soft) leh chhung lam (metal) protective sleeves, trocar pin, leh porous wire guide te a ni.b Insertion handle te hi protective sleeve leh pawn lam (soft) leh chhung lam (metal) protective sleeve, a trocar pin, leh a porous wire kaihhruaina. Trocar needle hi protective sleeve leh insertion handle nen an inzawm khawm a ni.b Mounting handle lateral ventilation holes nei. Insertion handle chunga knob hian handle assembly chu accidental disengagement a veng thei a ni

4 Guidewire chu dah la, a awmna tur chu siamrem rawh

Figure 8a Handle assembly chu patella hnuaiah patellofemoral joint kaltlangin tibia-a entry point duh lam pan chuan dah a ni (Figure 9). A tam zawkah chuan instrument dah laiin patella chu medial emaw laterally emaw-ah tlem a kal ang. Patellofemoral joint-a groove hian trocar needle chu a awmna tur dik takah automatic-in a kaihruai tlangpui.

Fig. 8b Plane pahnihah hian fluoroscopy hmangin position an finfiah a, a tulna hmunah siamthat a ni. Chumi hnuah trocar needle chu porous guidewire hmangin thlak a ni a, chu chu guidewire center hole kal tlangin a tip chu proximal tibial metaphysis-ah dahin a awmna dik tak a awm theih nan a ni.

Figure 8c Guidewire chu suboptimal position-a a awm chuan, guidewire pahnihna hmangin porous guidewire hmangin hmun tha zawkah siamthatna tlemte siam theih a ni a, a tam berah 4.3 mm thleng A danglamna chu guidewire atanga tan a, a luh theihna tur hmun tha ber ah unaided dah a awlsam zawk mai thei. Chumi hnuah chuan guidewire nei insertion instrument chu guidewire chungah a tlan lut leh a.

5 Medulla oblongata tihzauh

Fig. 9a Medullary cavity chu ideal entry point atanga hawn hi surgical procedure-a thil pawimawh tak a ni. Anteroposterior plane-ah chuan hei hi lateral tibial spur medial aspect a ni. Lateral plane-ah chuan entry point dik tak chu articular surface leh anterior cortex inkar transition-ah a awm a.

Fig. 9b Guidewire awmna dik tak chu anteroposterior plane-a tibial axis nen a inmil a, lateral projection-ah chuan anterior cortex nena parallel hnaih thei ang bera awm a ni. Guidewire hi hnunglam hawiin a kal duh hle.

Figure 9c Pin emaw nail emaw dah dik theih lohnaah chuan nail emaw pin emaw block hian nail chu a awmna tur dik takah a hruai thei a ni. 

Blocking nail hi metaphyseal region zau zawkah chuan guidewire emaw nail emaw chu ruh longitudinal axis nen parallel-a centered theih loh emaw, nail insertion laiin plane pakhat emaw pahnih emawa fracture misalignment a awm reng chuan hman a ni.

Figure 10 Hetiang dinhmunah hian handle assembly chu 3.2 mm guide wire hmanga femoral condyle-ah nghet taka dah a tha. Hei hian assembly chu tibia atanga a chhuah theih loh phah a ni.

Figure 11 12.0 mm hollow drill bit chu internal protective sleeve kaltlangin guidewire kaltlangin ruh thlengin dah a ni. Medullary canal chu cm 8-10 thuk thlenga drilling hmanga hawn a ni a, ball-ended guidewire chu proximal tibia-ah dah a ni.

6 Fracture tihziaawmna

Figure 12a Hetiang dinhmunah hian fracture chu kan reset a.

Figure 12b Fracture awmna hmun leh a morphology a zirin reduction tools chi hrang hrang percutaneous clips, retractors, small fragment plates, leh blocking screws te hmangin alignment dik tak neih theih a ni. Proximal tibial fracture tihziaawmnaah chuan, a chang chuan implant dang puihnain pawh, drilling hmanga medullary canal hawn hmain. Reaming rod hi distally-ah hmasawn a ni a, distal tibial metaphysis lai takah dah a ni. Repositioning hnuah nail sei zawng leh diameter an teh thin. A tul chuan tibial canal chu 0.5 mm increment-a reaming hmangin diameter duh angin ti lian tur a ni. Protective sleeve handle-a hawnna hian reaming laiin joint atanga bawlhhlawh awmte chu flush leh suction theihna a siamsak a ni. A theih chuan nail diameter tlem ber 10 mm hman a tha. Hetiang nail chi hrang hrang atana 5.0 mm Locking Bolt hi nail finer zawka hman thin 4.0 mm Locking Bolt aiin a chhe thei lo zawk a ni. Intramedullary nail sei zawng hi fluoroscopic ruler hmanga teh a ni tlangpui.

7Intramedullary nail dah tur a ni

Fig. 13a Fluoroscopy hmanga reaming rod hmanga nail dah luh. Hriat tur chu suprapatellar nail atana insertion handle hi infrapatellar nail aiin a sei zawk a, a chhan chu vun incision atanga tibial nail entry point thleng pawh a sei zawk a ni.

Figure 13b Khawngaihin hre reng ang che, intramedullary nail proximal end-a bend (Herzog curve) chu internal metal protective sleeve hmangin a lut thei lo. Chuvangin, nail dah hmain internal protective sleeve chu handle assembly atangin lakchhuah a ngai a ni (b; section 'Errors, Dangers and Complications' en rawh). Intramedullary nail awmna hnuhnung ber chu anterior-posterior leh lateral view-ah enfiah rawh. Reaming rod chu la chhuak rawh. Nail thlak a ngai a nih chuan reaming rod chu a hmunah dah la, nail thar chu rod chhungah dah rawh. Insertion handle-a 5 mm marking hian proximal tibia-a implant dah thukzia a tarlang a (Fig. 14). (Thlalak 14) 1.1.

8 Distal leh proximal locking a awm

Figure 14a Proximal leh distal locking configuration hi fracture characteristic bik a innghat a ni. Proximal locking hi aiming arm hmangin tih theih a ni. Distal locking hi freehand emaw radiopaque drill guide hmanga tih theih a ni. A duh chuan end cap hman theih a ni a, chu chuan ruh chu intramedullary nail proximal end-ah a lo thang lian thei lo va, a hnua implant lakchhuah a awlsam phah bawk. A bik takin, nail over-inserted te hi end cap sei tawk hman a nih chuan lakchhuah a awlsam zawk. End cap sei zawng duh chu handle-a mark dah emaw, aiming arm hmanga guide wire dah emaw hmangin teh a ni.

Figure 14b Guidewire tip hian intramedullary nail awmna proximal position a tarlang a. End cap dah tur chuan aiming arm leh nail thlunzawmtu screw chu lakchhuah a ngai a ni. End cap chu insertion handle barrel chhungah a kal tlang a. Insertion handle chu a hmunah a awm reng a ni. Hei hian end cap chu intramedullary nail chunglam nen a align a, khup chhungah a bo lo. Barrel end cap hmanga guidewire chu nail proximal end-a dah hian end cap chu intramedullary nail proximal end-a a awmna tur dik takah a hruai thei bawk. Procedure tawp lamah chuan sterile saline solution chu silfai tur a ni a, chu chuan debris particle awm zawng zawng chu a silfai vek tur a ni.

04. Fimkhur tur

Surgical Operation atana fimkhur dan tur

- Osteoarthritis awm tawhah chuan patellar motion khap tlat hian joint access a tikhawlo thei. Medial lam atanga medial emaw lateral support band proximal portion incision hian trocar pin insertion a ti awlsam hle.

- Ipsilateral knee prosthesis hi suprapatellar pinning hman lohna tur khauh tak a ni lo. Mahse, proximal tibial nailing procedure bul tanna pangngai chu a thleng thei lo mai thei tih hre reng ang che.

- Articular extension nei fracture-ah chuan articular fracture component chu immobilize turin screw dang dah belh theih a ni. Articular fracture secondary displacement a awm loh nan nail insertion hmain heng screw te hi dah hmasak a tha.

Proximal Tibia Fracture chungchang ngaihtuah tur

Proximal tibial fractures hi tibial fracture nail harsa ber a ni a, entry point dik tak (a chunga kan sawi tawh ang khan) a ngai a ni. Heng fracture te hi nailing hmain tihtlem tur a ni a, chu chuan deforming force eng pawh do let a, hlawhtlinna a tipung thei ang. A then phei chuan a natna chu semi-extended position-a dik taka dah a, entry point dik tak hmuh a, nail chu medullary canal nena coronal leh sagittal axes-a dah chuan nail hnuah tibia chu a alignment tha hle ang.

Mahse, a tam zawkah chuan heng fracture te hi satisfactory repositioning hmuh leh vawn reng tur hian reduction maneuver engemaw zat a ngai thin. Fracture line chu simple leh angled a nih chuan nailing laiin reset hmuh leh vawn reng nan simple pointed resetting clamp emaw coaptation clamp emaw, percutaneous-a dah te hman theih a ni. Clamp a tling tawk lo emaw, fracture plane chu clamping-ah a inlen loh chuan pollen emaw blocking screw emaw hian displacement leh malposition a veng thei a ni (Figure 15). Heng screw te hi lateral view-a nail position duhna hnung lamah dahin, anterior-posterior view-ah nail position duhna lateral-ah dah a ni. Reset tha tak neih theih nan heng screw te hi uluk taka dah chu thil harsa tak a ni thei.

Fig. 15 Locking screw te chu hmalam leh hnung lam (a)-a nail path duhzawng pawn lama dah leh side view (b)-a nail path duhzawng hnung lama dah te, deformation force te dodaltu

Technique tangkai tak dang chu a fracture chu anatomic position-ah temporary fixation a ni (Fig. 16). A tlangpuiin fragment tubular plate te tak te, single cortical locking screw pahnih emaw pathum emaw nei chuan root canal buatsaih leh nail insertion laiin fracture tihtlem chu a vawng tlat ang. Plate hian displacement pahnih hi a control ang. Plate lakchhuah hnua a awm fo thin reduction hloh tur ven nan gap fixed a awm loh chhung chuan plate chu a hmunah dah tur a ni. He plate cortical screw pakhat nei hi a rigid lo va, nail relative stability a nghawng dawn lo. Reset plate technique hi open leh closed fracture tan pawh hman theih a ni.

Figure 16 Cortical screw pakhat nei locking plate te tak te chu hmuh theih a ni a, anatomic reposition-ah dah theih a ni. A tam zawkah chuan plate chu nail hnuah a hmunah dah tur a ni. a Proximal tibial fracture atanga valgus deformity hmasa ber. b Nailing laiin fracture repositioning hmuh leh vawng reng turin cortical screw pakhat nei fracture plate te tak te chu medial-ah dah a ni. c Nailing hnuah plate hi lakchhuah a ni lo a, a chhan chu additional stability a pe a ni

Misalignment, Hlauhawm leh Harsatna awm thei te

- Intraoperative displacement of the Protective Sleeve hian cartilage leh intra-articular knee structures a tichhia thei (Figure 17). Protective sleeve chu a pumin a dah leh tur a ni.

- Protective Sleeve hi a tilt tlem chuan reamer head extraction a tizual thei. Fluoroscopy hmang hian harsatna chu hriat theih a ni. Protective sleeve siamthat leh chuan harsatna chu a chinfel sak ang (Fig. 18) .

- Nail Lock-Up: Implant chu proximal bend (Herzog curve)-ah metal sleeve-ah a tlakbuak thei. Final nail insertion atan chuan metal tube chu lakchhuah a ngai a, pawn lam soft plastic sleeve chauh a awm. Nail a tlak chuan a pumin lakchhuah leh a ngai a, plastic cannula hmang chauha metal cannula lakchhuah hnuah implant chu dah leh a ngai a ni.

Figure 17 Fluoroscopic observation tel lova protective sleeve lakchhuah hian khup hliam a thlen thei

Figure 18 a Protective casing tilting emaw accidental tilting emaw hian reamer lakchhuahna a tibuai thei a, reamer lu chu a jam thei a ni. b Alignment correction hmanga fluoroscopic inspection hmangin reamer lu chu lakchhuah theih a ni. c Reamer lu chu a hmunah a awm loh chuan lakchhuah theih a ni. d Reamer lu chu a hmunah a awm loh chuan lakchhuah theih a ni.

Thuhmahruai

Hessmann MH, Buhl M, Finkemeier C, Khoury A, Mosheiff R, Blauth M. A rilru a hah lutuk chuan a rilru a buai em em a, a rilru a hah lutuk chuan a rilru a buai em em bawk a. A rilru a buai em em a, a rilru a hah em em bawk a. 2020 Oct;32(5):440-454 ah a awm a.