Femoral Intramedullary Nailing - Momwe Mungasankhire Malo Olowera Abwino Kwambiri?

Mawu Oyamba

Kukula kwa chithandizo cha kuthyoka kwa chikazi kungayambike m'zaka za m'ma 1940 pamene Kuntscher adayambitsa njira yotsekedwa ya intramedullary nailing. Kugwiritsiridwa ntchito kwa misomali ya intramedullary (IMNs) mu fractures yachikazi kwakhala muyezo wa chisamaliro pazaka makumi angapo zapitazi, ndi kusintha kwaposachedwa. misomali ya intramedullary ndi kupita patsogolo kwa njira zopangira opaleshoni kwapangitsa kuti pakhale kuwonjezeka kwakukulu kwa kugwiritsa ntchito misomali ya intramedullary ya femur.

ndiwofatsa mankhwala a chikazi tsinde fractures ntchito ochepa kwambiri odwala ndi contraindications kwambiri kuti opaleshoni ndi opaleshoni, ndi nkhokwe ya chithandizo akhala opaleshoni fixation. Pankhani ya chithandizo cha opaleshoni ya fractures, pali njira zingapo zomwe zilipo, kuphatikizapo intramedullary nailing, plate screw fixation, ndi kukonza kunja. Poyerekeza ndi njira zina zopangira opaleshoni, misomali ya intramedullary ndiyo njira yomwe imakhala yochepetsetsa kwambiri komanso yochepetsera machiritso a fracture, ndipo ikugwiritsidwa ntchito kwambiri pazachipatala.

Kumvetsetsa bwino kwa thupi la proximal femur, kutuluka kwa magazi kumutu wa chikazi ndi maonekedwe a minofu ya m'chiuno kungapangitse kwambiri kupambana kwa intramedullary misomali chifukwa cha fractures ya chikazi. Mosiyana ndi zimenezi, kusankha malo olowera kumadalira zinthu zambiri, kuphatikizapo mapangidwe a misomali ya intramedullary, malo ophwanyika, fracture comminution, ndi zifukwa za odwala (mwachitsanzo, polytrauma, mimba, ndi kunenepa kwambiri). Mosasamala kanthu za malo olowera omwe asankhidwa, kupeza malo olowera oyenera ndikofunikira kuti muchepetse kuchepa kokwanira pakuyika msomali wa intramedullary ndikuchepetsa kuopsa kwa zovuta.

Femoral Anatomy

1.Kupereka magazi kumutu wa chikazi

Mutu wa chikazi umalandira mitsempha kuchokera ku mitsempha yayikulu ya 3. The lateral rotator femoral artery (yokhala ndi nthambi za 3-4), mitsempha ya obturator, yomwe imapereka mitsempha yozungulira, ndi mitsempha yapakati yozungulira yachikazi (mkuyu.

2.Anatomy Of The Hip Muscles

Pochita misomali ya intramedullary ya femur, kumvetsetsa bwino minofu yomwe ili pafupi ndi rotor ndikofunikira kuti tipewe kuvulala kosafunika. Minofu ya gluteus medius imachokera ku ilium ndipo imathera pambali ya trochanter yaikulu, pamene minofu ya gluteus minimus imachokera ku ilium ndipo imadutsa kumbuyo kwa chiuno cha mchiuno kuti ifike kumapeto kwa trochanter yaikulu (Zithunzi 2 & 3). Minofu yonseyi imagwira ntchito ngati adductors a ntchafu ndi ozungulira mkati mwa chiuno. Choncho, kuwonongeka kwa minofuyi pakuyika msomali wa paracentric femoral intramedullary kumapangitsa kuti pakhale kufooka kwa adductor ndi Trendelenburg gait, zomwe zimakhudza kwambiri kuchira kwa odwala ndi zotsatira zake.

Chithunzi 2. Anatomy ya minofu yozungulira mgwirizano wa chiuno

Chithunzi 3. proximal femoral muscle attachment area

Parallel Femoral Intramedullary Nail

Kafukufuku angapo aposachedwa awona malo abwino kwambiri olowera paracrine femoral misomali. Zosankha zolowera msomali zimaphatikizapo trochanter yayikulu ndi pyriform fossa, iliyonse ili ndi ziwonetsero zake komanso zovuta zomwe zimagwirizana (Table 1).

Table 1.Kuyambira ndi kuopsa kwa paracrine ndi retrograde femoral kukhomerera
zosiyana	misomali yofanana ya intramedullary		retrograde intramedullary msomali
	rotor	pyriform fossa (anatomy)
ndege ya korona	Vertex ya trochanter yayikulu ndikulozera pakati ku medullary cavity	mphambano ya khosi lalikulu la trochanter ndi femoral	wapakati wa intercondylar fossa (anatomy)
ndege ya sagittal (math.)	Mzere pakati pa pakati pa trochanter wamkulu ndi pakati pa fupa la m'kati mwa femur	pyriform fossa (anatomy)	PCL 1.2 masentimita kutsogolo kwa chikazi poyambira, kuloza ku medullary cavity.
zowonetsera	Gulu la Hip abductor gulu loyimitsa malo ovulala	Kuwonongeka kwa magazi kumutu wa chikazi ndi minofu yozungulira ya m'chiuno	Kusagwira bwino kungayambitse PCL
PCL: posterior cruciate ligament

1.Large rotor singano polowera

The trochanter yaikulu yafotokozedwa kuti ndi yakunja ya trapezoidal bony protuberance yomwe ili pambali ya khosi lachikazi, pamwamba pake yomwe imapereka kugwirizanitsa ndi lateral gluteus medius ndi anterior gluteus minimus muscles (Zithunzi 2 ndi 3). Ngakhale kuti ichi ndi chizindikiro chaching'ono cha mafupa, kuyika poyambira poyambira popanga IMN yachikazi kungakhale kusiyana pakati pa kupeza zotsatira zokhutiritsa kapena zoyipa pothana ndi kusweka kwa tsinde lachikazi.

Kuwunikanso zolemba zaposachedwa za malongosoledwe a malo achikazi, tapeza kusowa kwachidziwitso chofotokozera momveka bwino cha cholowa cha femoral rotor IMN.Bharti et al. adalongosola malo olowera kuchokera kumtunda wamtunda wa trochanter wamkulu kukhala pakati pa medullary cavity mu orthostatic position, komanso kukhala pakati pa trochanter yaikulu mogwirizana ndi pakati pa femoral medullary cavity mu lateral position (Mkuyu 4), ndi kufotokozera kwina kwa malo olowera kwambiri a trochanter pamphepete mwa chiuno chapakati pakati pa kutsogolo kwa chiuno ndi kutsogolo kwapakati ndi kutsogolo kwa kutsogolo ndi kumbuyo. magawo awiri pa atatu a rotor.Georgiadis et al. adalongosola nsonga yolowera singano ngati mbali yakumbuyo kwambiri yamphepete mwa apical apamwamba a rotor.

CHITHUNZI 4. Intraoperative orthostatic and lateral view of the hip amasonyeza malo abwino olowera kwa femoral paramedian intramedullary nailing of the trochanter yaikulu. '*' ikuwonetsa polowera msomali.

Kafukufuku waposachedwapa m'mabuku asonyeza kuti nsonga ya trochanter yaikulu ndiyo njira yabwino yoyambira kuti mupeze mzere wokwanira wa mphamvu, komanso kuti kusamvana kosauka chifukwa cha kusokonezeka kwa inversion nthawi zambiri kumachitika pamene mfundo yolowera imasinthidwa kuposa 2 mm lateral kupita ku trochanter yaikulu. Kafukufukuyu adatsindikanso kuti malo olowera kumbuyo kwambiri amatsogolera ku distal patsogolo, pomwe malo olowera apakati angapangitse kuti distal fracture block isunthidwe kumbuyo. Mosiyana ndi zimenezi, kafukufuku wina anasonyeza kuti mu intertrochanteric femur fractures, zochitika za intramedullary msomali zinali zapamwamba kwambiri ndi nsonga yokhotakhota yomwe inali yotsatizana ndi mbali yakumbuyo kusiyana ndi nsonga yomwe inali pafupi ndi mbali zapakati ndi zam'mbuyo.

Malo akuluakulu a trochanteric apex pinning point amagwiritsidwa ntchito kwambiri kwa odwala onenepa kwambiri, ndipo njirayi siyovuta mwaukadaulo, ikupereka nthawi yocheperako komanso chiwopsezo chochepa cha zovuta kuposa pyriform fossa pinning point.

ZOTHANDIZA: Zovuta za intraoperative ndi postoperative za femoral intramedullary nailing ndi njira yowonjezereka ya trochanteric zakambidwa m'mabuku angapo. Chimodzi mwa izi, chomwe nthawi zambiri chimakhudzana ndi njira yokhomerera misomali, chimakhala chothyoka chifukwa chamankhwala. Mu intertrochanteric femoral fractures, malo olowera omwe ali pambali ndi kutsogolo kwa trochanter yaikulu amatha kupangitsa kuti pakhale kupasuka kwapakati kusiyana ndi malo olowera pafupi ndi mbali yapakati.

Vuto lina lofunika ndilo chifukwa cha kuvulala kwa minofu yofewa, makamaka ku nthambi za mtsempha wachikazi wapakati ndi minyewa ya adductor, koma kuvulala kumeneku kumakhala kochepa kwambiri poyerekeza ndi pyriform fossa entry msomali. Kuonjezera apo, chiwerengero cha ischemic necrosis ya mutu wa chikazi ndi pamwamba pa trochanter yaikulu monga malo olowera amaganiziridwa kuti ndi otsika kwambiri, ndi maphunziro omwe amafotokoza kuti ndi otsika kwambiri ngati 0.3%.

Poganizira nthawi ya intraoperative ndi kuwonekera kwa fluoroscopic, nthawi yayitali yogwirira ntchito inali mphindi 90.7 polowera polowera kwambiri poyerekeza ndi mphindi 112.7 za gulu lolowera lamtundu wa peyala, pomwe nthawi ya fluoroscopic inali masekondi 5.88 pagulu lalikulu lolowera ndi 10. polowera fossa ngati peyala.

Kuzindikira kwa odwala kunalinso chinthu chofunikira posankha malo olowera msomali wa intramedullary, popeza kuchira koyambirira (monga momwe kuyesedwa ndi mayeso ampando wampando ndi kuyesa kwanthawi yayitali) kunali bwino kwambiri kwa odwala pamiyezi ya 6 pambuyo pogwira ntchito polowera kwambiri polowera ku trochanteric poyerekeza ndi pyriform fossa polowera msomali, koma kusiyana kumeneku sikunali kofunikira pakapita miyezi 12. Ngakhale kuti malo opitako kwambiri a trochanteric nthawi zambiri amagwirizanitsidwa ndi kuvula minofu yofewa chifukwa cha malo ake, amatha kuvulaza gulu la abductor minofu, monga momwe Ergiş et al asonyezera. Iwo adapeza kuti mphamvu zolimbitsa thupi komanso mphamvu za hip abductor zidachepetsedwa mwa odwala omwe ali ndi chikhomo chachikulu cholowera ku trochanteric poyerekeza ndi kuwongolera kwathanzi. Kuonjezera apo, kafukufuku wawo adawonetsa kuchepa kwakukulu kwa mphamvu za olanda chiuno, zosinthika ndi zozungulira zamkati / zakunja poyerekeza ndi mbali yosagwira ntchito.

2. Pearly fossa polowera

The fossa of the pyriformis muscle ndi chizindikiro chofunikira cha anatomical chodziwika kuti ndi chimodzi mwazolowera za paracentesis femoral intramedullary nail. Mu kafukufuku wawo wa autopsy cadaveric, Lakhwani et al. adazindikira kuti fossa ya minofu ya pyriformis sinali 'peyala' yowoneka bwino kapena cholumikizira minofu ya pyriformis. Minofu imamangiriza ku malo ang'onoang'ono kumapeto kwa trochanter yaikulu, pamene pyriform fossa ndi kuvutika maganizo kumbali yapakati ya trochanter yaikulu ndipo ndi chophatikizira cha extensor carpi radialis brevis muscle. Olembawo adatsimikiza kuti minofu ya pyriform ndi pyriform fossa ndi zinthu ziwiri zosiyana ndipo zomwe zimatchedwa pyriform fossa ziyenera kutchedwa 'rotor' kapena 'occlusal' fossa kuti zimveke bwino komanso zolondola za anatomical. Iwo adanena kuti ataphunzira za cis-femoral Iwo adanena kuti mawu oyambirira 'rotor fossa' abwezeretsedwenso m'mabuku m'malo mwa 'pyriform fossa' ataphunzira mawu a parafemoral entry point. Ngakhale kuti mfundo za maphunziro awiriwa zimayamikiridwa kwambiri, kuti zikhale zosavuta kufotokozera komanso kupewa chisokonezo ndi malo olowera kwambiri a trochanteric, tidzatchulanso malowa ngati malo olowera pyriform fossa.

Maphunziro angapo m'mabuku amakono amafotokoza bwino lomwe malo olowera a ngale fossa ya intramedullary femoral nails.Georgiadis et al. fotokozani polowera pearly fossa monga malo omwe amamangiriridwa ndi extensor carpi radialis brevis muscle mu kuvutika maganizo pamunsi pa khosi lachikazi (mkuyu 5). Olembawo adatsindikanso kuti malo olowera omwe ali kutali kwambiri kapena kutali kwambiri akhoza kuonjezera chiopsezo cha kuphulika kwa khosi lachikazi, ndipo pamene malo olowera ali kutali kwambiri, pangakhale chiopsezo chachikulu cha ischemic necrosis, chomwe chimakhala chachikulu kwa odwala achinyamata.

Chithunzi 5. Intraoperative frontolateral view ya chiuno chosonyeza malo abwino olowera pyriform fossa retrograde femoral intramedullary msomali. '*' ikuwonetsa poyambira msomali wa intramedullary.

Harper et al. linasindikiza kafukufuku wa 14 magulu a anthu cadaveric femurs mu 1987 momwe iwo kuwunika malo a intramedullary kalozera pini ndi kuchoka mfundo ya intramedullary msomali anayambitsa distal ndi proximally mu mafashoni retrograde kuchokera intercondylar mphako wa femur. Iwo anaganiza kuti mfundo yolowera pyriformis paramedian intramedullary msomali inali pamphepete mwa trochanter yaikulu ndi khosi lachikazi, pang'ono kutsogolo kwa pyriformis occulta.Malo olowetsamo adatsimikiziridwa ndi Gausepohl et al. Mu kafukufuku wina wa cadaveric, adayika malo abwino olowera misomali yachikazi ya intramedullary m'mphepete mwapakati pa trochanter yayikulu yomwe ili pamwamba pa pyriformis tendon. Kuphatikiza apo, mu kafukufuku wa cadaveric wa Labronici et al. fossa ya minofu ya pyriformis inafotokozedwa ngati dera lowala lokhala ngati peyala lomwe limagwirizana ndi chigawo chapakati cha femoral intramedullary cavity mu ndege ya coronal.

Malo ofikira a pyriform fossa ali ndi zovuta zina chifukwa ndizovuta kwambiri poyerekeza ndi malo ofikira a trochanter, makamaka odwala onenepa kwambiri. Kuonjezera apo, malo abwino kwambiri olowera malo olowera singano ngati peyala ndi malo opapatiza, zomwe zimapangitsa kuti zikhale zovuta kuti anthu azikhalamo. Mwachitsanzo, poyambira kwambiri pakhosi lachikazi kumapangitsa kuti pakhale kupsinjika kwakukulu kozungulira ndikuwonjezera chiopsezo cha kuphulika kwa kortical anterior, makamaka ngati poyambira ndikupitilira 6 mm kutsogolo kwa fossa. Kuonjezera apo, kusiyana kwa morphologic kungalepheretse malo oyenerera olowera, makamaka ngati chozungulira chachifupi chakunja chiri chochuluka kapena chozungulira chikukwera, chomwe chimatsogolera kumalo olowera omwe ali apakati komanso chiopsezo cha kuphulika kwa khosi lachikazi.

ZOTHANDIZA: Poyerekeza malo 38 akuluakulu olowera trochanteric ndi malo 53 a pearly fossa olowera kwa femoral intramedullary nailing, Ricci et al adapeza kuti gulu la pearly fossa linali ndi 30% yotalikirapo nthawi yayitali komanso 73% nthawi yayitali ya fluoroscopy. Zotsatirazi zidatsimikiziridwa ndi Bhatti et al. poyerekezera 2 singano zolowera.

Ponena za kuvulala kwa minofu yofewa, panali chiopsezo chachikulu cha kuvulala kwa minofu yofewa pamtunda wa pyriformis poyerekeza ndi interosseous neuromuscular pa malo akuluakulu a singano a trochanteric. Dora et al. anawunika 16 akuluakulu a cadaveric femurs chifukwa cha kuvulala kwa minofu yofewa ku minofu ya pyriformis ndi pini yolowera. Iwo adapeza kuti ngakhale kuti pyriformis fossa inali geometrically mulingo woyenera kwambiri, izo zinayambitsa kuwonongeka kwakukulu kwa mitsempha yoperekedwa kumutu wa chikazi ndi minofu yozungulira ndi tendons. Zotsatirazi zidatsimikiziridwanso ndi maphunziro a cadaveric ndi Ansari Moin et al. WHO idafaniziranso magawo awiri olowera. Iwo adanena kuti kukonza mkati mwa msomali kuyambira pa minofu ya pyriformis kunali kovuta kwambiri kuwononga olanda chiuno ndi ozungulira kunja. Kuonjezera apo, kuwonongeka kwa mtsempha wapakati wa rotator femoral kunapezeka muzochitika zonse (Table 2).

Table 2. Chidule cha kuvulala kwa minofu yofewa pazigawo zosiyana za singano
zosiyana	Pyriform fossa polowera (n=5)	Malo odyetserako ozungulira (n=5)
minofu yofewa
gluteus medius minofu (anatomy)	5	1
gluteus medius tendon	0	4
kuvulala kwa tendon
gluteus minimus (anatomy)	3	0
pyriformis minofu (pamwamba pa msana)	3	3
obturator internus (anatomy)	1	0
latissimus dorsi minofu (anatomy)	3	0
Mitsempha yamagazi ndi makapisozi olowa
MFCA Deep Nthambi	4	0
MFCA Shallow Branch	4	0
articular capsule (yolumikizana monga bondo mu anatomy)	1	0
MFCA: medial circumflex femoral artery.

Posachedwapa, Bharti et al. adaphunzira za kuopsa kwa chiwopsezo cha chiwopsezo cha chikazi chokhomerera polowera kwambiri pa trochanteric polowera ndi pearly fossa polowera ndipo adapeza zovuta zowopsa monga kuchuluka kwa machiritso a fracture ndikuzifotokozera mwachidule motere (Table 3).

Table 3. Pyriform fossa polowera ndi chachikulu trochanter polowera femoral bone m`mafupa
zovuta	Piriformis sinus singano mfundo	Malo olowetsamo ma trochanter
Kupatsirana	6.7	3.3
Malunion	20	13.3
Kuchedwa kuchira	20	13.3
Kuyenda pang'ono kwa ntchafu	20	33.3
Kuyenda kwa mawondo ochepa	6.7	6.7
Kusiyana kwa kutalika kwa miyendo	13.3	20
Chovala chamchira chimatuluka pamwamba pa fupa la fupa	13.3	20
Intraoperative femoral khosi kuthyoka	10	0
Kuphulika kwakukulu kwa trochanter	0	3.4
Femoral mutu necrosis	6.7	0

Retrograde femoral intramedullary nailing

Kuzindikira malo oyenera olowera ku retrograde femoral intramedullary nailing kumathandizira kubwezeretsanso kusinthika kwabwino kwa fracture, kutalika, ndi kuzungulira pomwe kuchepetsa kuwonongeka kwa cartilage, anterior cruciate ligament (ACL), posterior cruciate ligament (ACL), ndi kuvulala kwa minofu yofewa (Table 1). Posachedwapa, pakhala chiwongola dzanja chowonjezeka cha retrograde femoral intramedullary nailing ndi cholinga chochepetsera mavuto omwe amabwera chifukwa cha misomali ya paracromial, kuphatikizapo kupweteka kwa m'chiuno, heterotopic ossification, kufooka kwa adductor, ndi pudendal nerve palsy, zomwe zimaganiziridwa kuti ndizochepa kwambiri poyerekeza ndi kuchepetsa kuchepetsa ndi kutseketsa mkati mwa femoral plating. wa tsinde lachikazi. Kuonjezera apo, umboni waposachedwa umasonyeza kuti pamene misomali yobwezeretsa intramedullary ili ndi kukula kwake koyenera, misomali yotsekera yoyandikana nayo singafunikire.Panalibe kusiyana pakati pa machiritso, nthawi ya machiritso, kapena zotsatira za odwala pakati pa Meccariello et al. ndi Bisaccia et al. pochiza distal gawo limodzi mwa magawo atatu a femoral tsinde fractures ntchito kutseka ndi nonlocking retrograde intramedullary misomali. Choncho, ntchito retrograde femoral misomali wakhala wotchuka ndi ambiri anavomereza.

Mafotokozedwe ambiri a malo abwino kwambiri olowera ku retrograde femoral intramedullary nailing angapezeke m'mabuku. Kafukufuku wambiri amapeza malo abwino olowera msomali wobwerera kumbuyo monga 1.2 anterior kwa chiyambi chachikazi cha posterior cruciate ligament.

masentimita (mogwirizana ndi medullary cavity) ndi pakati pa intercondylar fossa (Chithunzi 6).

CHITHUNZI 6. Intraoperative orthostatic and lateral view of bondo kusonyeza malo abwino olowera ku retrograde femoral intramedullary msomali. '*' ikuwonetsa poyambira msomali.

Ngakhale palibe chisonyezero chenicheni cha retrograde femoral intramedullary kukhomerera, zizindikiro zambiri zachibale zafotokozedwa. Izi zikuphatikizapo odwala polytrauma, odwala onenepa kwambiri, odwala omwe ali ndi pakati, tsinde lachikazi lachikazi, tsinde lachikazi lachikazi komanso fractures ya acetabular / pelvic kapena fractures ya khosi lachikazi, komanso tsinde lachikazi ndi fractures ya tibial. Zambiri mwazizindikirozi zimakhudzana ndi kumasuka kwa malo odwala komanso kupewa mabala angapo opangira opaleshoni pafupi.

Kumbali ina, zotsutsana mtheradi pakubwezeretsanso misomali yachikazi ya intramedullary imaphatikizapo kutsekeka kwa njira ya retrograde intramedullary ndi implant yomwe idasungidwa komanso kutseguka kwa distal femur. Zotsutsana zofanana ndi zosweka zomwe zili mkati mwa 5 masentimita a trochanter yaying'ono, kuvutika kupeza malo abwino olowera chifukwa cha kupindika kwa bondo kosachepera madigiri a 45, matenda am'mbuyo a mawondo omwe angayambitse chiopsezo chofalikira ku tsinde lachikazi, kuvulala kwakukulu kwa minofu yofewa kuzungulira bondo, ndi kuthyoka kwa intra-articular ndi pole ya disfeterital pole.

Zovuta: Zovuta zambiri za misomali yachikazi yobwerera kumbuyo imakhudzana ndi kusagwira bwino, makamaka kuyika kolakwika kwa malo olowera. Mu ndege ya sagittal, malo olowera kutsogolo kwambiri angapangitse kumasulira kwapambuyo kwa fracture, kuwonongeka kwa pamwamba, ndipo mwinamwake kuponyedwa kwa misomali pa patella pamene bondo likugwedezeka. Kumbali ina, ngati malo olowera ali molakwika kumbuyo, izi zingapangitse chiopsezo chachikulu cha kuvulala kwa chiyambi cha posterior cruciate ligament ndi kusamuka kwapambuyo kwa malo ophwanyika.

Hutchinson et al. adalongosola zovuta zomwe zimagwirizanitsidwa ndi malo osayenera olowera ndege. Iwo adapeza kuti malo olowera mkati mopitilira muyeso adapangitsa kuti pakhale kupunduka kwa posterolateral ndi kumasulira kwa posterolateral fracture, pomwe kupendekera kopitilira muyeso kumapangitsa kupunduka kwapakati komanso kumasulira kwapakatikati.Sanders et al. inanena kuti kusankha malo oyambira apakati omwe anali 2 cm kapena kupitilira apo kumapangitsa kuti pakhale kusweka kwapakati kwapakati komwe kunali malunited chifukwa champhindi yakumbuyo ya isthmic yopindika yomwe imapangitsa kuchepa kwapambuyo kwapambuyo.

Zovuta zina zomwe zimagwirizanitsidwa ndi misomali yachikazi yobwereranso kumaphatikizira kupweteka kwa mawondo, kuuma, kukomoka kwa mawondo a heterotopic, komanso mapangidwe a thupi lopanda mawondo a intra-articular.

Pomaliza

Ngakhale njira iliyonse ya intramedullary misomali imakhala ndi chizindikiro chofananira, kusankha kwa njira yopangira misomali ya intramedullary kuti igwiritsidwe ntchito pochiza minyewa yachikazi nthawi zambiri zimatengera zomwe dokotala wachita. Pochita misomali ya intramedullary ya femur, kupeza malo oyenera olowera mtundu wa msomali womwe umagwiritsidwa ntchito kukonza ndikofunikira kuti pakhale zotsatira zabwino. Kudziwa za momwe thupi lanu limagwirira ntchito komanso momwe mungaganizire zimathandizira dokotalayo kuti achite njira yoyenera mwaukadaulo ndikuchepetsa chiopsezo cha zovuta zomwe zingachitike. Kuonjezera apo, mu njira zopangira misomali ya intramedullary, kukonzanso kuchepetsa ndi gawo lofunika kwambiri poletsa malunion ndi malunion kapena kusagwirizana kwa fractures.