Tibial fractures, suprapatellar intramedullary misomali njira

Njira ya intramedullary nailing kwa tibial fractures: kupyolera mu suprapatellar, transarticular njira ndi bondo losunthika pa 20-30 ° ndi chubu chapadera chotetezera kuteteza mapangidwe a intra-articular.

01.Tibial Intramedullary Nailing: kupeza ndi kuyanjanitsa, kupweteka kwapambuyo kwa bondo

Kupeza opaleshoni ya intramedullary nailing of tibial fractures ndikofunikira kuti muyike msomali wa intramedullary polowera polowera, kuchepetsa kuwonongeka kwa maondo a intra-articular, ndikukwaniritsa kukhazikika bwino kwa fracture ndi kulowa msomali woyenera.

Njira zachikale za kuphulika kwa tibial stem ndi njira zapakatikati za infrapatellar kapena parapatellar. Ngakhale kuti njirazi zimasonyezedwa pakatikati pa fractures, postoperative valgus, anterior, kapena syndesmotic deformities nthawi zambiri zimachitika m'mitsempha yowonjezereka.

Chifukwa chachikulu cha kusalongosoka kwa proximal tibial fractures ndi kupunduka komwe kumachitika chifukwa cha kukoka kwa tendon ya quadriceps panthawi ya mawondo a mawondo ndi mkangano wamakina pakati pa nsonga ya msomali ndi posterior tibial cortex panthawi yoika implants. Patella imalepheretsanso kulowa kwa axial kwa msomali mu ndege ya sagittal (Mkuyu 1a, b). Choncho, njira ina yodziwika bwino yolowera mfundoyi ndi kudzera muzitsulo zapakati pa parapatellar, zomwe zimabweretsa kuyika kwa msomali pang'ono (Fig. 1c ndi 2). Pamene msomali umalowa mu intramedullary canal distal mpaka fracture, gawo lokhazikika limapendekera mu exostosis (mkuyu 2). Potsirizira pake, mpumulo wopumula wa minofu ya m'chipinda cham'mbuyo imathandizira pang'ono ku ectropion (mkuyu 3).

Chithunzi 1 a, b Pogwiritsa ntchito njira yodziwika bwino ya infrapatellar, patella imalepheretsa kulowa kwa axial kwa msomali, zomwe zimapangitsa kuti pakhale kufooka kwapadera kwa anterior apical apical sagittal alignment ndi ectropion coronal alignment.c Intramedullary nail alignment inkachitidwa pogwiritsa ntchito njira ya parapatellar.

Chithunzi 2 Kuyandikira polowera kudzera pakatikati pa parapatellar incision kumapangitsa kuti pang'onopang'ono kulowetse msomali. Pamene msomali umalowa mu ngalande ya medullary mpaka kuthyoka (a), gawo loyandikana nalo limapendekera mumoto (b)

Chithunzi cha 3 Kupumula kwa chigawo chapakati cha minofu (a) kumapanga dongosolo la ectopic (b)

Kukhomerera tibia pamalo otalikirapo kumathandiza kupewa zovuta zomwe zimagwirizanitsidwa ndi kupindika kwa mawondo a intraoperative.Njirayi inafotokozedwa ndi Gelbke, Jakma et al. mu 2010 ndipo atchuka kwambiri m'zaka zaposachedwa chifukwa kukhomerera tibia pafupi ndi mwendo wowongoka kumapangitsa kuti fracture ikhale yosavuta ndikuyikanso. Fluoroscopy yakhala yosavuta kuchita mwaukadaulo. Nthawi ya fluoroscopy ya kukhomerera kwa suprapatellar yanenedwa kukhala yayifupi kwambiri kuposa yokhomerera infrapatellar. Kuonjezera apo, msomali wolowetsa msomali (mu ndege ya sagittal) umafanana kwambiri ndi kutalika kwa tibia ndi njira iyi kusiyana ndi misomali ya infrapatellar; izi zimalepheretsa kukangana kwamakina pakati pa nsonga ya msomali ndi posterior cortex, potero zimathandizira kuchepetsa kusweka.

Kupweteka kwa bondo pambuyo pa opaleshoni ndi vuto loyenera. Kupweteka kwapambuyo kwa mawondo kunanenedwa mu 50-70% ya odwala omwe ali ndi fractures, ndi 30% yokha ya odwala omwe amamva kupweteka pambuyo pochotsa mapeto. Kupanga kwa zipsera zokhudzana ndi kupezeka kwa tendon ya patellar ndi mafuta a Hoffa akuti ndizomwe zimayambitsa kupweteka kwa bondo pambuyo pa opaleshoni. Kuonjezera apo, njira ya suprapatellar imapewa kudulidwa kwachizoloŵezi chodula nthambi ya patellar nthambi ya mitsempha ya saphenous, yomwe imapewa dzanzi lakumbuyo la bondo ndi kukhumudwa (Chithunzi 4). Kudutsa msomali kudzera mu quadriceps tendon, motero kusiya patellar tendon, kumawoneka kuti kumachepetsa kwambiri ululu wa pambuyo pa opaleshoni ya bondo.

Chithunzi cha 4 Ubale pakati pa mitsempha ya saphenous ndi njira zosiyanasiyana zopita ku tibialis obliqua msomali.

Chifukwa cha zotsatira zabwino za ma fractures a proximal, zisonyezo muzochita zachipatala zafalikira ku fractures zonse.

Mavuto omwe angakhalepo ndi misomali ya intramedullary mu njira ya suprapatellar:

- Akhoza kusiya zinyalala zobwerera m'mawondo. Komabe, zokumana nazo zachipatala ndi retrograde femoral nailing sizinawonetse zotsatira zazifupi kapena zazitali.

- Kodi implant imachotsedwa bwanji kuthyoka kwake kuchira? Ngakhale ndizotheka mwaukadaulo kuchotsa msomali wa intramedullary kudzera mu njira ya suprapatellar, njirayo ndiyofunikira ndipo madokotala ambiri ochita opaleshoni amakonda kuchotsa msomali wa intramedullary kudzera mu njira ya infrapatellar.

02.Kodi msomali wa suprapatellar intramedullary uyenera kugwiritsidwa ntchito liti?

Ubwino wake

- Malo otalikirapo a mawondo amathandizira kuphwanya ndikuchepetsa pakupumula mphamvu za minofu ndikusungidwa pakuyika misomali.

- Chiwopsezo chochepa cha kusayenda bwino kwapambuyo, gawo, ndi distal fractures poyerekeza ndi njira zachikhalidwe

- Kukhomerera ndikosavuta kuchita mwaukadaulo

- Kukhomerera misomali ndizotheka ngati 'njira ya opaleshoni imodzi'.

- Kuchepetsa nthawi ya fluoroscopy

- Palibe kuwonongeka kwa tendon ya patellar komanso kuchepa kwa kupweteka kwapambuyo kwa misomali

- Zosavuta kuchita munjira yamagulu angapo, monga ndi polytrauma.

Zoipa

- Kuopsa kwa kuwonongeka kwa mawondo a mawondo ndi zida zina za intra-articular

- Kuwonjezeka kwa chiopsezo cha matenda a bondo

- Kuchotsa implantation kungafune njira ina

Zizindikiro

- Kuphulika kwapang'onopang'ono kwa proximal tibia (Mtundu wa AO 41A)

- Kuphulika kosavuta kwa tibial diaphysis (mtundu wa AO 42A-C)

- Segmental tibial diaphysis fracture (mtundu wa AO 42C)

- Zowonjezera zowonjezera komanso zosavuta zowonjezera zamkati za distal tibia (mitundu AO 43A ndi C1)

- Bondo loyandama

Contraindications

- Gustilo giredi 3C kutseguka kwa fractures kwa tibia chifukwa cha chiopsezo chowonjezereka cha matenda olowa, ngakhale chiopsezo chowonjezereka cha matenda olowa nawo sichinanenedwe pakuthyoka kotseguka.

- Kung'ambika kwakukulu, kuipitsidwa kapena matenda m'dera la suprapatellar

- Ipsilateral bondo prosthesis (chibale contraindication)

- Kuphatikizika kwa bondo

- Kukula kwa bondo kupitirira 20 °

- Kuphulika kwa Ipsilateral tibial Plateau komwe kumakhudza malo olowera msomali ndikotsutsana.

- Zovala zotsekereza polowera msomali

- Ipsilateral patella fracture (zosagwirizana nazo)

03. Njira zopangira opaleshoni

① Maonekedwe a thupi ndi momwe amawonera

Chithunzi cha 5 Wodwalayo amagona pa tebulo la radiolucent lomwe limalola kugawanika kwa mwendo. Chiwalo chosweka chimasiyidwa chikulendewera momasuka ndipo mpukutu umayikidwa pansi pa bondo (a) kuti ukwaniritse 10-30 ° ya kupindika kwa bondo. 

(b). C-mkono waikidwa mbali ina. Mwendo wosakhudzidwa umatsitsidwa 10-30 ° kuchokera kumtunda kuti muwonetsetse kujambula koyenera kumalo ozungulira.

②Pezani polowera singano yoyenera

Chithunzi 6 Njirayi imadziwika ndi shaft ya patella, tibial tuberosity, ndi anterior tibial cortex. Kupaka khungu kwa 2 cm kwautali kumapangidwa 1-1.5 cm moyandikana ndi malo apamwamba a patella. Minofu ya quadriceps imawululidwa ndipo kudulidwa kwapakati pa nthawi yayitali kumapangidwa motsatira ulusi wa tendon. Kupuma kwa suprapatellar kumatsegulidwa ndipo zala za dokotalayo zimalowa m'mphepete mwa bondo kuchokera pansi pa patella kuti ziwone mosavuta. Kutambasula pang'ono kwa mwendo kungathandize kuti munthu apite ku kneecap. Kuyika kwa Langenbeck retractor kuti mukweze pang'ono patella kungapangitsenso mwayi wopezeka. Ngati malo olowa nawo ndi opapatiza kwambiri ndipo zida zimakhala zovuta, gulu lothandizira lapakati kapena lothandizira likhoza kupangidwa moyandikana nalo kuti lisokoneze theka la patella kumbali imodzi.

③Kuteteza chichereŵechereŵe

Chithunzi 7 Kutetezedwa kwa cartilage ya patellofemoral kuchokera ku kuvulala kokhudzana ndi opaleshoni ndi chimodzi mwa zolinga zazikulu za opaleshoni. Choncho, manja otetezera ayenera kugwiritsidwa ntchito panthawi ya zida ndi kuyika misomali.a Zida zogwiritsira ntchito transarticular zimaphatikizapo zogwirira ntchito, zakunja (zofewa) ndi zamkati (zitsulo) zoteteza manja, zikhomo za trocar, ndi ma porous wire guides.b Zomwe zimalowetsamo zimasonkhanitsidwa ndi manja otetezera ndi kunja (zofewa) ndi mkati (zitsulo) zotetezera pin, atrocarous pin, waya. Singano ya trocar imasonkhanitsidwa ndi manja otetezera ndi chogwirira cholowetsa.b Chogwirizira chokhala ndi mabowo olowera mpweya wabwino. Mphuno yomwe ili pamwamba pa chogwirira choyikapo imalepheretsa kusokoneza mwangozi kwa chogwiriracho

④ Ikani chiwongolero ndikusintha malo

Chithunzi 8a Msonkhano wothandizira umayikidwa pansi pa patella kupyolera mu mgwirizano wa patellofemoral kupita kumalo omwe mukufuna kulowa pa tibia (Chithunzi 9). Nthawi zambiri, patella imasuntha pang'ono pang'onopang'ono kapena mozungulira panthawi yoyika chida. Mphepete mwa mgwirizano wa patellofemoral nthawi zambiri imatsogolera singano ya trocar kuti ikhale yoyenera.

Chithunzi cha 8b Malo adatsimikiziridwa mu ndege zonse pogwiritsa ntchito fluoroscopy ndikuwongolera ngati kuli kofunikira. Singano ya trocar imasinthidwa ndi porous guidewire, chowongolera chomwe chimadutsa pakati pa dzenje la guidewire ndipo nsonga yake imalowetsedwa mu proximal tibial metaphysis kuti atsimikizire malo oyenera.

Chithunzi 8c Pamene chiwongolerocho chili ndi malo ocheperapo, chiwongolero chachiwiri chingagwiritsidwe ntchito kupanga zosintha pang'ono pamalo abwino kupyolera mu porous guidewire, mpaka kufika pamtunda wa 4.3 mm Monga njira ina, zingakhale zosavuta kuyamba ndi guidewire ndikuyiyika mopanda chithandizo pamalo abwino olowera. Chida choyikira chokhala ndi waya wolozera ndiye amatsetsereka panjira.

⑤ Kukula kwa medulla oblongata

Chithunzi 9a Kutsegula khomo la medula kuchokera pamalo abwino olowera ndi gawo lofunika kwambiri pakupangira opaleshoni. Mu ndege ya anteroposterior, iyi ndi mbali yapakati ya lateral tibial spur. Mu ndege yam'mbali, malo olowera olondola amapezeka pakusintha pakati pa articular surface ndi anterior cortex.

Chithunzi cha 9b Malo olondola a guidewire akugwirizana ndi tibial axis mu ndege ya anteroposterior komanso pafupi ndi kufanana ndi cortex ya anterior momwe zingathere poyang'ana kutsogolo. Wowongolerayo amakonda kusuntha cham'mbuyo.

Chithunzi 9c Pamene pini kapena msomali sungakhoze kuikidwa bwino, kutsekereza msomali kapena nsomali kumathandiza kutsogolera msomali pamalo oyenera. 

Misomali yotchinga imagwiritsidwa ntchito m'dera lalikulu la metaphyseal pamene chowongolera kapena msomali sichingagwirizane ndi kutalika kwa fupa la fupa kapena pamene kupasuka kolakwika mu ndege imodzi kapena zonsezi kumakhalabe panthawi yoyika msomali.

Chithunzi 10 Pakadali pano, tikulimbikitsidwa kuti chogwiriracho chikhale chotetezedwa ku kondomu yachikazi pogwiritsa ntchito waya wowongolera wa 3.2 mm. Izi zimalepheretsa msonkhano kuchoka pa tibia.

Chithunzi 11 Bowolo la 12.0 mm limayikidwa kudzera m'manja oteteza mkati ndikutsika kudzera pawaya wolowera kufupa. Mtsinje wa medullary umatsegulidwa pobowola mpaka kuya kwa masentimita 8-10 ndipo chingwe chowongolera mpira chimayikidwa mu proximal tibia.

⑥ Kuchepetsa kusweka

Chithunzi 12a Panthawiyi, timakhazikitsanso fracture.

Chithunzi 12b Malingana ndi malo a fracture ndi morphology yake, zida zosiyanasiyana zochepetsera monga ma percutaneous clips, retractors, mbale zazing'ono, ndi zomangira zotchinga zingagwiritsidwe ntchito kuti zigwirizane bwino. Mu proximal tibial fracture kuchepetsa, nthawi zina ngakhale mothandizidwa ndi ma implants owonjezera, musanatsegule ngalande ya medullary pobowola. Ndodo yobwezeretsa imapita patsogolo kwambiri ndipo imayikidwa pakati pa distal tibial metaphysis. Pambuyo pokonzanso, kutalika ndi kutalika kwa msomali zimatsimikiziridwa. Ngati ndi kotheka, kulitsa ngalande ya tibial mpaka m'mimba mwake yomwe mukufuna mwa kubwerezanso mu increments 0.5 mm. Kutsegula kwa chogwirira cha manja oteteza kumalola kutulutsa ndi kuyamwa zinyalala kuchokera pagulu panthawi yobwezeretsanso. Ngati n'kotheka, ndi bwino kugwiritsa ntchito msomali wosachepera 10 mm. 5.0 mm Locking Bolt ya mtundu uwu wa misomali imakhala yolimba kwambiri kulephera kuposa 4.0 mm Locking Bolt yomwe imagwiritsidwa ntchito pa misomali yabwino kwambiri. Kutalika kwa misomali ya intramedullary nthawi zambiri kumatsimikiziridwa ndi wolamulira wa fluoroscopic.

⑦ Ikani msomali wa intramedullary

Chithunzi 13a Kulowetsa msomali kudzera mu ndodo yobwezeretsanso pansi pa fluoroscopy. Zindikirani kuti chogwirira choyikapo cha msomali wa suprapatellar ndi wautali kuposa msomali wa infrapatellar chifukwa mtunda wochokera pakhungu kupita kumalo olowera msomali umakhalanso wautali.

Chithunzi 13b Chonde dziwani kuti kupindika (Herzog curve) kumapeto kwa msomali wa intramedullary sikungalowetsedwe kudzera muchitetezo chamkati chachitsulo. Chifukwa chake, chotchinga chamkati chamkati chiyenera kuchotsedwa pamsomali musanalowetse msomali (b; onani gawo 'Zolakwa, Zowopsa ndi Zovuta'). Yang'anani malo omaliza a msomali wa intramedullary pamawonedwe apambuyo-pambuyo ndi kumbuyo. Chotsani ndodo yobwezeretsanso. Ngati msomali ukufunika kusinthidwa, siyani ndodoyo pamalo ake ndikulowetsa msomali watsopano mu ndodoyo. Zizindikiro za 5 mm pa chogwirira choyikapo zimasonyeza kuya kwa kuyika kwa implant mu proximal tibia (mkuyu 14). (Chithunzi 14)

⑧ Distal ndi proximal kutseka

Chithunzi 14a Kukonzekera kwapakatikati komanso kotsekeka kwa distal kumadalira mawonekedwe enaake osweka. Kutseka kwapang'onopang'ono kumatha kuchitika ndi mkono wolunjika. Kutseka kwa distal kumachitika mwaulere kapena pogwiritsa ntchito chiwongolero cha radiopaque. Mwachidziwitso, kapu yomaliza ingagwiritsidwe ntchito, yomwe imalepheretsa fupa kukula mpaka kumapeto kwa msomali wa intramedullary ndikuthandizira kuchotsedwa kwa implant. Makamaka, misomali yolowetsedwa mopitirira muyeso imakhala yosavuta kuchotsa pamene zipewa zomalizira za kutalika koyenera zimagwiritsidwa ntchito. Utali wofunidwa wa kapu yakumapeto umayesedwa mwa kulowetsa chizindikiro pa chogwirira kapena polowetsa waya wolondolera m'dzanja lolunjika.

Chithunzi 14b Nsonga ya chiwongolerocho imasonyeza malo oyandikira a msomali wa intramedullary. Chomangira cholumikiza mkono wolunjika ku msomali chiyenera kuchotsedwa kuti muyike kapu yomaliza. Chophimba chomaliza chimadutsa mumgolo wa chogwirira cholowetsa. Chogwirizira cholowetsa chimakhalabe. Izi zimagwirizanitsa kapu yomaliza ndi pamwamba pa msomali wa intramedullary ndikuletsa kuti isatayike mu bondo. Kulowetsa chowongolera kudzera pa kapu yomaliza ya mbiya kumapeto kwa msomali kumathandizanso kuwongolera chipewacho kuti chifike pamalo ake oyenera kumapeto kwa msomali wa intramedullary. Kumapeto kwa ndondomekoyi, madzi a saline osabala amayenera kutsukidwa kuti achotse zinyalala zilizonse zotsala.

04. Chenjezo

Kusamala Pochita Opaleshoni

- Pankhani ya osteoarthritis yomwe ilipo kale, kuyenda kocheperako kumatha kulepheretsa kulumikizana. Kudulidwa kwa gawo loyandikira la gulu lothandizira lapakati kapena lakumbuyo kuchokera kumbali yapakati kumathandizira kuyika pini ya trocar.

- Prosthesis ya bondo yosagwirizana ndi mawondo sikotsutsana kwambiri ndi pinning ya suprapatellar. Zindikirani, komabe, kuti sikungatheke kupeza njira yoyambira yokhazikika ya proximal tibial nailing process.

- Pazophwanyika zokhala ndi zowonjezera, zomangira zowonjezera zitha kuyikidwa kuti zisamayendetse gawo la fracture ya articular. Ndikofunikira kuti zomangira izi ziyikidwe musanayambe kuyika misomali kuti mupewe kusamuka kwachiwiri kwa fracture ya articular.

Malingaliro a Proximal Tibia Fracture

Proximal tibial fractures ndizovuta kwambiri za tibial fractures kuti zikhale misomali ndipo zimafuna malo enieni olowera (monga tafotokozera pamwambapa). Zosweka izi ziyenera kuchepetsedwa musanakhomedwe kuti zithetse mphamvu zilizonse zopunduka ndikukulitsa kupambana. Nthawi zina, kuyika bwino chiwalo chokhudzidwacho pamalo otalikirapo komanso kupeza malo olowera ndikuyika msomali ndi ngalande ya medullary m'makona a coronal ndi sagittal kumapangitsa kuti tibia ikhale yoyenera pambuyo pokhomerera.

Komabe, nthawi zambiri, kuwongolera kwina kochepetsera kumafunika kuti mupeze ndikusunganso kukonzanso kokhutiritsa kwa fractures izi. Ngati mzere wosweka ndi wosavuta komanso wopindika, zingwe zowongolera zokhazikika kapena zolumikizira, zoyikidwa molunjika, zitha kugwiritsidwa ntchito kupeza ndikusunganso kukonzanso panthawi yokhomerera. Ngati chotchingacho sichikukwanira kapena ndege yothyoka sichitha kukakamiza, mungu kapena zomangira zotsekera zingathandize kupewa kusamuka komanso kusakhazikika bwino (Chithunzi 15). Zomangira izi zimayikidwa chakumbuyo kwa malo omwe msomali womwe ukufunidwawo poyang'ana chakumbali ndi kutsogolo kwa malo omwe msomali womwe ukufunidwa pamawonedwe akumbuyo-wakumbuyo. Kuyika koyenera kwa zomangira izi kuti mukhazikitsenso bwino kungakhale kovuta.

Chithunzi 15 Zomangira zokhoma zomwe zimayikidwa kunja kwa njira yofunidwa ya misomali kutsogolo ndi kumbuyo (a) ndi kuseri kwa njira yomwe misomali yomwe mukufuna m'mbali mwake (b) motsutsana ndi mphamvu zopindika.

Njira ina yothandiza kwambiri ndikukonza kwakanthawi kwa kusweka kwa malo a anatomic (mkuyu 16). Nthawi zambiri mbale yaying'ono yokhala ndi zomangira ziwiri kapena zitatu za kotekisi imodzi imasunga chothyokacho chochepetsedwa panthawi yokonzekera ngalande ndi kuyika misomali. Mbaleyi idzawongolera kusamuka konse. Mbaleyo iyenera kusiyidwa pokhapokha ngati palibe kusiyana kokhazikika kuti muteteze kutayika kwa kuchepetsa komwe kumachitika kawirikawiri pambuyo pochotsa mbale. Chimbale ichi chokhala ndi screw imodzi ya cortical sichiri cholimba ndipo sichidzakhudza kukhazikika kwa msomali. Njira yokhazikitsiranso mbale ingagwiritsidwe ntchito paziphuphu zotseguka komanso zotsekedwa.

Chithunzi 16 Kamba yaing'ono yokhoma yokhala ndi screw imodzi ya cortical imatha kupezeka ndikusungidwa mu mawonekedwe a anatomiki. Nthawi zambiri mbaleyo iyenera kusiyidwa pamalo ake pambuyo pokhomerera. Kuwonongeka koyambirira kwa valgus kwa kupasuka kwapakatikati kwa tibial. b Mbale yaing'ono yothyoka yokhala ndi zomangira imodzi ya cortical imayikidwa pakati kuti ipeze ndi kusunga fracture repositioning panthawi yokhomerera. c Mbaleyo simachotsedwa pambuyo pokhomerera chifukwa imapereka kukhazikika kwina

Kusalinganiza, Zowopsa ndi Zovuta

- Kusamuka kwa intraoperative kwa Sleeve yotetezera kungayambitse kuwonongeka kwa cartilage ndi mawondo a intra-articular (Chithunzi 17). Chotetezacho chiyenera kubwezeretsedwanso kwathunthu.

- Kupendekeka pang'ono kwa Sleeve Yoteteza kumatha kukulitsa kutulutsa mutu kwa remer. Fluoroscopy imathandiza kuzindikira vutoli. Kukonzanso kwa manja oteteza kumathetsa vutoli (mkuyu 18)

- Kutsekera Msomali: Choyikacho chikhoza kumamatira mu manja achitsulo pa mapindikidwe apatali (Herzog curve). Poika misomali yomaliza, chubu lachitsulo liyenera kuchotsedwa, kusiya manja apulasitiki ofewa akunja okha. Msomali utakamatidwa, uyenera kuchotsedwanso kwathunthu ndikubwezeretsanso choyikapo pambuyo pochotsa chitsulo chachitsulo kudzera mu cannula ya pulasitiki yokha.

Chithunzi 17 Kuchotsa manja oteteza popanda kuyang'ana fluoroscopic kungayambitse kuvulala kwa mawondo

Chithunzi 18 Kupendekeka kapena kupendekeka mwangozi kwa chotchinga choteteza kumatha kusokoneza kuchotsedwa kwa reamer, chifukwa mutu wa reamer ukhoza kupanikizana. b Kuwunika kwa fluoroscopic ndi kuwongolera koyenera kumalola kuchotsedwa kwa mutu wa reamer. c Mutu wa reamer ukhoza kuchotsedwa ngati mutu wa reamer suli m'malo. d Mutu wa reamer ukhoza kuchotsedwa ngati mutu wa reamer suli m'malo.

Maumboni

Hessmann MH, Buhl M, Finkemeier C, Khoury A, Mosheiff R, Blauth M. Suprapatellar misomali ya fractures ya tibia. Oper Orthop Traumatol. 2020 Oct; 32 (5): 440-454.