Tibial Intramedullary Nail Fixation Technique

Kukonzekera kwa msomali wa intramedullary kumakhalabe chithandizo chosankhidwa kwa fractures ya tibial stem yosakhazikika komanso yosasunthika mwa akuluakulu. Cholinga cha chithandizo cha opaleshoni ndi kubwezeretsa kutalika, kugwirizanitsa ndi kusinthasintha kwa tibia ndi kukwaniritsa machiritso a fracture. Ubwino wa misomali ya intramedullary ndi kuvulala kochepa kwa opaleshoni komanso kusungidwa koyenera kwa magazi omwe amathyoka. Kuphatikiza apo, misomali ya intramedullary ya tibia imapereka kukhazikika koyenera kwa biomechanical fracture ndipo imakhala ngati chipangizo chogawana katundu chomwe chimalola kulimbikitsana koyambirira pambuyo pa opaleshoni. Kupita patsogolo kwa kapangidwe ka misomali ya intramedullary ndi njira zochepetsera zakulitsa zisonyezo za intramedullary fixation kuti ziphatikizepo proximal tibia ndi kutsika kwapakati pachitatu fractures.

Mpaka lero, kuchepetsa kutsekedwa kwa misomali ya intramedullary fractures ya tibial yakhala njira yodziwika bwino ya opaleshoni ya opaleshoni ya mafupa. Ngakhale kutchuka kwa intramedullary misomali kukonza kwa tibial stem fractures, kumakhalabe kovuta ndipo kumakhala ndi zovuta zambiri. Njira za opaleshoni zikupitirizabe kusintha. Cholinga cha nkhaniyi ndi kufotokoza mfundo zamakono mu intramedullary misomali fixation wa tibial tsinde fractures ndi kufotokoza mwachidule patsogolo m'munda.

一. Kuwunika koyambirira ndi kuyendera

Odwala aang'ono, tibial stem fractures nthawi zambiri amakhala chifukwa cha kuvulala kwamphamvu kwambiri, ndipo odwala ayenera kuyesedwa chifukwa cha kupwetekedwa mtima kogwirizana ndi malangizo a Advanced Trauma Life Support (ATLS). Onani kuvulala kozungulira khungu ndi minofu yofewa monga matuza ophwanyika, zotupa pakhungu, kuyaka, ecchymosis, kapena kukwera kwapakhungu; fotokozerani ngati kupasukako kuli kotseguka, ndipo ngati kuli koyenera kuchitira kafumbata ndi maantibayotiki; ndikuwunika mwatsatanetsatane zaubongo ndikulemba zomwe zili pamwambapa. Unikani zomwe zimachitika kwa osteofascial compartment syndrome ndikuchita mayeso angapo azachipatala mwa odwalawa.

Kafukufuku waposachedwapa wasonyeza kuti chiwerengero cha osteofascial compartment syndrome pambuyo pa tibial tuberosity fractures chikhoza kufika 11.5%. Makamaka, magulu ang'onoang'ono odwala amatha kukhala ndi osteofascial compartment syndrome. Kuzindikira kwa osteofascial compartment syndrome kuyenera kutengera zomwe zapezeka m'chipatala, kuphatikizapo kupweteka kwambiri, kusintha kwa mitsempha, kutupa kwa chipinda cha myofascial, komanso kupweteka kwapang'onopang'ono chifukwa cha kukula kwa chala. Choncho, osteofascial compartment syndrome imakhalabe chidziwitso chachipatala ndipo zolemba zonse zachipatala ndizofunikira. Kupanikizika mkati mwa chipinda cha myofascial kungayesedwe pogwiritsa ntchito singano yokakamiza (Chithunzi 1) ngati njira yowonjezera yowunikira mayeso apadera.

Chithunzi 1. Kuyeza kupanikizika mu interosseous septum pogwiritsa ntchito singano yokakamiza.

Kuti mupeze deta yodalirika, kupanikizika kwa intrafascial kuyenera kuyesedwa m'magulu anayi a myofascial komanso m'malo osiyanasiyana mkati mwa chipinda chilichonse cha myofascial. Kafukufuku m'mabuku akuwonetsa kuti kutsika kwapakati kochepera 30 mmHg (kuthamanga kwa diastolic minus fascial compartment) kukuwonetsa matenda a fascial compartment. Kuthamanga kwa diastolic nthawi zambiri kumachepa panthawi ya opaleshoni, ndipo kupanikizika kwa diastolic kuyenera kuganiziridwa powerengera kusiyana kwa mphamvu.

Kafukufuku waposachedwapa wasonyeza kuti kuwunika kwa intrafascial pressure ndi chida chothandiza pozindikira matenda aacute fascial compartment syndrome, kumva kwa 94% ndi 98%. Komabe, chifukwa cha zotsatira zowononga kwambiri za compartment syndrome, matenda a compartment syndrome ayenera kukhala okhudzana ndi zomwe apeza, ndipo miyeso ya interosseous compartment pressure iyenera kugwiritsidwa ntchito pazochitika zapadera, monga pamene wodwalayo wavulala kapena pamene mfundo zachipatala sizikudziwika bwino.

Kuwunika kojambula kuyenera kuphatikizapo ma orthopantomograms ndi mawonedwe amtundu wa tibia ovulala ndi ma radiographs a bondo loyandikana ndi mafupa a akakolo, omwe amawunikidwanso pogwiritsa ntchito computed tomography (CT). Momwemonso, CT scan ya bondo ingakhale yofunikira kuti muwone mizere yosweka yomwe ikupita kumtunda wa tibial ndi kuvulala kosagwirizana ndi ankle.

二. Zovuta zachipatala

Chiwerengero chachikulu cha fractures chapakati chapakati pachitatu cha tibia ndi fractures ya ankle chanenedwa. Pogwiritsa ntchito ma CT scans, 43% ya fractures yapakati ndi m'munsi mwa magawo atatu a tibia adatsagana ndi fractures ya m'miyendo, yomwe ambiri ankafuna chithandizo cha opaleshoni. Mtundu wodziwika kwambiri wa fracture unali fracture ya spiral ya m'munsi mwachitatu cha distal tibia yomwe imagwirizanitsidwa ndi kuphulika kwapang'ono kapena kosasunthika kwapambuyo kwapambuyo (Chithunzi 2). Chifukwa cha kuchepa kwapang'onopang'ono kwa fracture yolumikizana ndi bondo, 45% yokha ya kuvulala kumatha kudziwika pama radiographs a ankle. Choncho, chizolowezi cha CT scans cha bondo chiyenera kutsindika kwambiri pamene fracture yapakati ya tibia ilipo (mkuyu 3).

Chithunzi 2.AF Spiral kuthyoka kwa m'munsi mwachitatu wa tibia kumanja (A, B) Ma radiographs asanayambe opaleshoni a m'bowo amasonyeza bwino (C). Intraoperative C-arm fluoroscopy imasonyeza kupasuka kwapambuyo kwa bondo (D) Postoperative radiographs pambuyo pokonza opaleshoni (EF) kumasonyeza machiritso osalala a tibial ndi fractures.

Chithunzi 3. AF Spiral fracture yapakati ndi m'munsi mwachitatu cha kumanzere tibia (AB) radiographs preoperative; (CD) preoperative CT scans yosonyeza kuphulika kwapambuyo kwa malleolar kopanda malo; (EF) kusonyeza machiritso osadziwika a tibia ndi malleolar fracture

三. Njira zopangira opaleshoni

01. Tibial Needle Entry Point

Kukhazikitsa malo olowera molondola kumagwira ntchito yofunika kwambiri ndipo maphunziro ambiri m'mabuku apereka chidziwitso chofunikira pa malo a anatomical a malo abwino olowera kwa intramedullary nailing of tibial fractures. Maphunzirowa awonetsa kuti malo abwino opangira pinning ali pamphepete mwa nyanja ya tibial ndipo amangokhala pakati pa lateral tibial spur. Malo otetezeka okhala ndi 22.9 mm ± 8.9 mm, omwe samayambitsa kuwonongeka kwa zomangira zoyandikana nawo, adanenedwanso. Mwachizoloŵezi, chiyambi cha intramedullary misomali yokhazikika ya tibial stem fractures yakhazikitsidwa kudzera mu njira ya infrapatellar, mwina mwa kugawaniza patellar tendon (transpatellar approach) kapena kuchotsa mbali ya patellar tendon stop (njira ya paratendinous).

Semi-extension intramedullary misomali yakopa chidwi kwambiri m'mabuku aposachedwa a mafupa, ndipo Tornetta ndi Collins akuwonetsa kuti agwiritse ntchito njira yapakatikati ya parapatellar kuti akhazikitse mkati mwa msomali pamalo otalikirapo kuti apewe kutuluka kwa msomali wa intramedullary kupita ku anterior tibial cortex mu paramedulla yamkati3. theka-extension malo akulimbikitsidwanso. Kugwiritsiridwa ntchito kwa njira ya suprapatellar kwa tibial intramedullary nailing ndi kuyika kwa msomali wa intramedullary kupyolera mu mgwirizano wa patellofemoral mu malo otalikirapo akulimbikitsidwa.

Njirayi imachitidwa ndi bondo losinthasintha pafupifupi madigiri 15-20, ndipo kudulidwa kwautali pafupifupi 3 centimita kumapangidwa pafupifupi chala chimodzi kapena ziwiri m'lifupi pamwamba pa patella. Minofu ya quadriceps imagawanika motalika kwambiri ndipo kutayika kosasunthika kumapangidwira mu mgwirizano wa patellofemoral. Chophimba chosasunthika chimayikidwa kupyolera mu mgwirizano wa patellofemoral kuti apange malo olowera pamtunda wa proximal anterior tibial cortex ndi articular surface (Chithunzi 4).

Chithunzi 4. ab Zithunzi za intraoperative za (a) kugawaniza tendon ya quadriceps ndikulowetsa trocar kupyolera mu mgwirizano wa patellofemoral kupita kumalo olowera tibial; (b) mawonedwe a intraoperative lateral a malo olowera

Kubowola kwa 3.2 mm kumagwiritsidwa ntchito kudziwa poyambira singano motsogozedwa ndi C-arm. Soketi yokhala ndi perforated imaperekedwa kuti iwunikire bwino polowera ndi potuluka. Njira zotsalira zopangira opaleshoni kuphatikizapo kukonzanso ndi kuika msomali wa tibial amachitidwa kudzera muzitsulo.

ZOTHANDIZA ZOTHANDIZA: Malo otalikirapo mwendo angathandize kuti fracture ikhazikike, makamaka m'mafupa omwe ali ndi gawo limodzi mwa magawo atatu a tibia ndikuyang'ana kutsogolo. , Malo otalikirapo amatha kuthetsa kupsinjika kwa minofu ya quadriceps ndikuthandizira kukonzanso fracture. , The semi-extended position suprapatellar approach ingakhalenso njira ina ya infrapatellar yachikhalidwe (Chithunzi 5).

Chithunzi 5. Chithunzi cha intraoperative chosonyeza kuvulala kwa minofu yofewa m'dera la infrapatellar monga chisonyezero cha njira ya suprapatellar mu malo otalikirapo.

Kafukufuku wasonyeza kuti njira ya suprapatellar yokhomerera tibial intramedullary mu theka-extended position ndi njira yotetezeka komanso yothandiza opaleshoni. Mayesero azachipatala amtsogolo akufunika kuti apitirize kufufuza ubwino ndi kuipa kwa njira ya suprapatellar intramedullary nailing ndikuwunika zotsatira za nthawi yayitali zokhudzana ndi njirayi.

02. Bwezeraninso zamakono

Kuyika kwa tibial intramedullary msomali wokha sikupangitsa kuchepetsa kokwanira kwa fracture; Kuchepetsa koyenera kwa fracture kuyenera kusungidwa panthawi yonse yobwezeretsanso ndikuyika kwa msomali wa intramedullary. Kugwiritsa ntchito kukoka kwapamanja kokha sikungakwaniritse kuchepetsedwa kwa anatomiki pawokha. Nkhaniyi ifotokoza njira zingapo zotsekera, zosokoneza pang'ono, komanso zotseguka zochepetsera.

-Malangizo osinthika otseka

Njira zochepetsera zotsekedwa zimatha kutheka ndi chida chochepetsera monga chochepetsera F-fracture, chipangizo chochepetsera chochepetsera mawonekedwe a F-radiographically transmissible chomwe chimakonza ma inversion / exversion angles komanso kumasulira kwapakati / kutsogolo (mkuyu 6).

Chithunzi 6. F-woboola fracture reducer anatchula opaleshoni

Komabe, chipangizochi chikhoza kuika maganizo ochuluka pazitsulo zofewa, ndipo kugwiritsa ntchito nthawi yayitali chipangizo chobwezeretsanso chiyenera kupewedwa. Mphamvu zochepetsera zimatha kuyikidwanso molunjika, monga momwe zimakhalira ndi ma fractures ozungulira komanso oblique. Zidazi zingagwiritsidwe ntchito mofatsa minofu yofewa kudzera muzolowera zazing'ono (Chithunzi 7).

Chithunzi 7. Percutaneous clamping kuti mukhazikitsenso fracture ya tibial

Mtundu wa clamp ndi malo opangira opaleshoni ayenera kusankhidwa potengera njira yochepetsera kuwonongeka kwanthawi yayitali kwa minofu yofewa kuchokera pakuyika kwa clamp (Chithunzi 8).

Chithunzi 8. Fotokozeraninso mphamvu za repositioning kuti mukhazikitsenso fracture ya tibial

Ma retractor ndi chimodzi mwazinthu zomwe zimagwiritsidwa ntchito pobwezeretsa kutalika kwa tibia. Nthawi zambiri amayikidwa pakati komanso kutali ndi malo omwe msomali wa intramedullary uyenera kuyikidwa. Ma Proximal traction pins atha kuyikidwa kuti atsanzire malo otsekera otsekera, omwe amalola kuti fracture ichepetse mosavuta msomali wa intramedullary ukalowa.

Nthawi zina, njira zochepetsera zotsekedwa komanso zocheperako zimakhalabe zosakwanira kuti athe kuchepetsa thupi. Zikatero, njira zochepetsera zowonongeka ziyenera kuganiziridwa ndi kuyang'anira mosamala minofu yofewa yozungulira. Zoyipa zomwe zingatheke za njira zochepetsera poyera zimaphatikizapo kuvulala kowonjezera kwa opaleshoni, komwe kungapangitse chiopsezo cha matenda apamalo opangira opaleshoni. Kuonjezera apo, kuvula kowonjezera kwa magazi kumalo ophwanyika kungapangitse chiopsezo cha postoperative fracture nonunion.

-Maluso aukadaulo pakudula ndikusinthanso

Njira zochepetsera zochepetsera sizimaloleza mphamvu zochepetsera maopaleshoni zomwe zimayikidwa pamalo oyenera, komanso kugwiritsa ntchito timizere tating'ono kapena kakang'ono pamalo osweka kuti achepetse kusweka panthawi ya misomali ya intramedullary.

Ma mbale amatetezedwa ku tizidutswa ta proximal ndi distal fracture pogwiritsa ntchito zomangira za monocortical. Chigawocho chimasungidwa panthawi yonse yokonzanso ndikuyika msomali wa intramedullary mu tibia. Pambuyo poyika msomali wa intramedullary, mbaleyo inachotsedwa kapena kusiyidwa kuti ikhale yokhazikika (Chithunzi 9). Posiya mbaleyo m'malo mwake, screwcortical single cortical iyenera kusinthana ndi screw cortical double. Iyenera kuganiziridwa kuti igwiritsidwe ntchito pazochitika zomwe tibial tsinde imafuna opaleshoni yotseguka kuti ikwaniritse kuchepetsedwa kovomerezeka kwa fracture.

Chithunzi 9. Tsegulani tibia fracture ndi comminution kwambiri ndi fupa chilema, single cortical fixation ndi kachidutswa kakang'ono pamapeto osweka a fracture pambuyo kuchepetsa ndi kuchotsedwa kwa splint pambuyo intramedullary msomali fixation.

Cholinga cha msomali wotsekereza ndikuchepetsa pakatikati pa medullary m'chigawo cha metaphyseal. Misomali yotsekereza imayikidwa mkati mwa kachidutswa kakang'ono ka articular ndi kumbali ya concave ya kupunduka musanayambe kuyika kwa intramedullary misomali. Mwachitsanzo, kupunduka kwapakati pa gawo limodzi mwa magawo atatu a tibia kumadziwika ndi valgus ndi kutsogolo kwa angulation. Kuti akonze kuwonongeka kwa valgus, chotchinga chotsekera chikhoza kuyikidwa mu gawo lakumapeto kwa fracture ya proximal fragment (ie, mbali ya concave ya deformity) mu njira ya anteroposterior. Msomali wa intramedullary umayendetsedwa kuchokera kumbali yapakati, potero kuteteza valgus. Mofananamo, kupunduka kwa angulation kungagonjetsedwe mwa kuyika zotsekera zotsekera zapakati mpaka kumapeto kwa chipika cha proximal block (ie, mbali ya concave ya kupunduka) (Chithunzi 10).

Chithunzi 10. kuthandizira kukonzanso kwa tibial fracture mwa kuika misomali yotchinga

-Kukula kwapang'onopang'ono

Pambuyo pomaliza kubwezeretsanso fracture, kukonzanso kwa medullary kumasankhidwa kukonzekera fupa kuti lilowetse msomali wa intramedullary. Mphuno yopita ku mpira imalowetsedwa m'kati mwa tibial marrow ndikudutsa pamalo ophwanyika, ndipo kubowolanso kumadutsa pamtunda wodutsa mpira. Malo a otsogolera mpira adatsimikiziridwa pansi pa C-arm fluoroscopy kuti akhale pamtunda wa mgwirizano wamagulu, ndipo guidewire inali yokhazikika pamaganizo onse a anteroposterior ndi lateral (Chithunzi 11).

Chithunzi 11. chikuwonetsa malo a guidewire mu medullary cavity pa C-arm fluoroscopy kumalo akutsogolo ndi kumbuyo.

Nkhani ya medulla yokulitsidwa ndi yosakulitsidwa yakhala yotsutsana. Timakhulupirira kuti madokotala ambiri ochita opaleshoni ku North America amakonda misomali yowonjezera ya medullary intramedullary ya tibia kuti ikhale yosakulitsidwa. Komabe, misomali yowonjezereka komanso yosakulitsidwa ya intramedullary ingagwiritsidwe ntchito ngati njira zovomerezeka zovomerezeka, ndipo zotsatira zabwino zitha kupezeka ndi njira zonse ziwiri.

-Kuyika zotsekera zotsekera

Kugwiritsiridwa ntchito kwa zomangira zolumikizira mu tibial tsinde fractures cholinga kuteteza kufupikitsa ndi malrotation, kukulitsa zizindikiro za intramedullary kukhomerera tibia kuti proximal ndi distal tibial tsinde fractures kuphatikizapo metaphysis. M'mafractures okhudzana ndi dera la metaphyseal, zomangira zolumikizira zidakhala zofunika kwambiri pakusunga axial alignment.

Zomangira zitatu zolumikizirana zimathandizira kwambiri kukhazikika, ndipo zomangira zokhazikika zokhazikika pakona zingapereke kukhazikika kwakukulu kuposa zomangira zokhazikika, zomwe zitha kuloleza kukhazikika kwapangidwe komweko ndi zomangira zocheperako. Deta yachipatala pa chiwerengero ndi kasinthidwe ka zomangira zolumikizira zomwe zimafunikira kukonza mkati mwa tibia kukhalabe ochepa.

Kuyika kwa zomangira zolumikizirana nthawi zambiri kumachitika pogwiritsa ntchito kachulukidwe kolumikizidwa ndi nsonga ya intramedullary. Zomangira za distal interlocking zimayikidwa mwaulere motsogozedwa ndi fluoroscopic. Kugwiritsa ntchito makina owongolera omwe amathandizidwa ndi makompyuta kumalimbikitsidwa kuti muyike zomangira za distal tibial interlocking (Chithunzi 12). Njirayi imalola kuyika kopanda ma radiation kwa zomangira zolumikizirana za distal ndipo zawonetsedwa kuti ndi njira yotheka komanso yolondola.

Chithunzi 12.AB Zomangira zotsekera kudzera mukuwona kwa C-mkono; Ma CD Locking screws kudzera pa electromagnetic computer-assisted locking

Kuyika zomangira zolumikizirana ndi distal ndi njira yotetezeka yopangira maopaleshoni ndipo zomangira zolumikizira ziyenera kuyikidwa mwatsatanetsatane komanso mwaubwenzi.

Kafukufuku wa anatomiki wasonyeza kuti pali chiopsezo cha peroneal mitsempha palsy pamene kuyika proximal medial kuti lateral oblique interlocking zomangira. Kuti achepetse chiopsezochi, madokotala ochita opaleshoni ayenera kuganizira zoboola zomangira motsogozedwa ndi C-arm, ndi mbali ya fluoroscopic ya C-arm perpendicular kwa ndege ya kubowola. Kulowetsa mkati mwa cortex ya distal tibia kungakhale kovuta kuzindikira ndi tactile mayankho, ndipo kuyandikira kwa mutu wa fibula kukhoza kusokoneza chidziwitso cha tactile ndikupatsa dokotalayo kuganiza kuti ali 'm'fupa' pamene kwenikweni mutu wa fibula walowa. Kutalika kwa screw kuyenera kuzindikirika osati ndi kubowola komaliza komanso kuyeza koyenera. Kubowola kulikonse kapena kuyeza kutalika kwa 60 mm kuyenera kuyambitsa kukayikira kwa posterolateral protrusion, zomwe zitha kuyika mitsempha wamba pachiwopsezo chovulala.

Zomangira zakutali zakumbuyo ndi zam'mbuyo zimayikidwa mosamala ku chitetezo cha anterolateral neurovascular bundle, tibialis anterior tendon, ndi extensor digitorum longus. Ngakhale kuyika kwa percutaneous screw nthawi zambiri kumakhala kotetezeka, madokotala ochita opaleshoni ayenera kudziwa kuopsa kwa minofu yofewa yozungulira. Pazigawo zambiri za tibial stem fractures, zomangira ziwiri za proximal ndi ziwiri za distal interlocking zimapereka kukhazikika kokwanira. Kuphulika kwapakatikati ndi distal tibial fractures kungapindule ndi kuyika kwazitsulo zowonjezera zowonjezera mu ndege zosiyanasiyana kuti ziwonjezere kukhazikika kwa dongosololi (Chithunzi 13).

Chithunzi 13. Kuthyoka kangapo kwa tibia, kuchitidwa ndi misomali ya intramedullary ndi zomangira ziwiri za distal ndi zitatu zozungulira, ndi ma x-ray omwe amasonyeza kuchiritsidwa kwa fracture.

- Kukonzekera kwa Fibular

Mapangidwe amasiku ano a misomali ya intramedullary okhala ndi zomangira zotsekera zakutali zakulitsa zisonyezo za kukhomerera kwa intramedullary kwa tibia kuti aphatikizepo ming'alu yapakatikati ndi yakutali yomwe imakhudza dera la metaphyseal.

Masinthidwe osiyana a distal interlocking screw anagwiritsidwa ntchito mu phunziroli (zomangira 2 kuchokera ku medial kupita ku lateral motsutsana ndi 2 screws zoyikidwa perpendicular kwa wina ndi mzake ndi zonse 3 distal interlocking screws motsutsana ndi 1 distal interlocking screw). Odwala omwe adakumana ndi fibular fixation ndi tibial intramedullary nail fixation, mlingo wotayika wotayika unali wotsika kwambiri. Okwana 13 % ya odwala ndi intramedullary misomali fixation popanda fibular fixation anasonyeza pambuyo opaleshoni kutaya kukonzanso, poyerekeza ndi 4 % ya odwala tibial misomali fixation popanda fibular fixation.

Mu mayesero ena kuyerekeza mphamvu ya tibial intramedullary misomali fixation ndi fibular fixation ndi tibial intramedullary misomali fixation motsutsana ndi fibular fixation, odwala kuchitidwa ndi fibula fixation pamodzi ndi tibial misomali anasonyeza kusintha rotational ndi inversion/eversion kuyanjanitsa.

Timatsimikiza kuti adjunctive fibular fixation imakwaniritsa ndikusunga kuchepa kwa tibial fracture mu distal gawo limodzi mwa magawo atatu a tibia fractures omwe amapangidwa ndi intramedullary misomali. Komabe, vuto la zovuta zabala kuchokera ku zowonjezera zowonjezera m'dera la minofu yopwetekedwayo limakhalabe. Chifukwa chake timalimbikitsa kusamala pogwiritsira ntchito chithandizo cha fibular fixation.

03. Zotsatira

Intramedullary nailing fixation ya tibial stem fractures ikhoza kubweretsa zotsatira zabwino. Machiritso a misomali ya intramedullary ya tibia adanenedwa m'maphunziro osiyanasiyana. Pogwiritsa ntchito ma implants amakono ndi njira zoyenera za opaleshoni, machiritso akuyembekezeka kupitirira 90%. Kuchuluka kwa machiritso a tibial stem fractures omwe sanathe kuchira pambuyo pa kukhazikika kwa msomali wa intramedullary kunasintha kwambiri pambuyo pa kukhazikika kwamkati ndi msomali wachiwiri wowonjezereka wa intramedullary.

Kufufuza kwa zotsatira pa chaka chimodzi pambuyo pa opaleshoni kunasonyeza kuti mpaka 44% ya odwala anapitirizabe kukhala ndi malire ogwira ntchito m'munsi mwa ovulala, ndipo mpaka 47% anapitiriza kufotokoza kulemala kwa ntchito pa chaka chimodzi pambuyo pa opaleshoni. Kafukufukuyu akuwonetsa kuti odwala omwe amathandizidwa ndi misomali ya intramedullary ya tibia akupitirizabe kukhala ndi zofooka zogwira ntchito kwa nthawi yaitali. Madokotala ochita opaleshoni ayenera kudziwa za nkhaniyi ndikulangiza odwala moyenerera!

四. Zovuta za postoperative

01. Pre-patellar ululu

Ululu wam'mbuyo wa patellofemoral ndi vuto lodziwika bwino pambuyo pokonza misomali ya intramedullary ya tibial stem fractures. Kafukufuku wasonyeza kuti pafupifupi 47 % ya odwala pambuyo misomali intramedullary akhoza kukhala prepatellar ululu, etiology amene sadziwa bwinobwino. Zomwe zingayambitse zingaphatikizepo kuvulala koopsa komanso kwachipatala kwa mapangidwe a intra-articular, kuvulala kwa nthambi ya infrapatellar ya mitsempha ya saphenous, kufooka kwa minofu ya ntchafu yachiwiri mpaka kuponderezedwa kwa ma neuromuscular reflexes okhudzana ndi ululu, fibrosis ya mafuta pad yomwe imatsogolera ku kupindika, kugwedezeka kwa patellar tendonitis, kupindika pamwamba pa produlla ya produlla, kupindika pamwamba pa produlla ya produlla. kutuluka kwa msomali wapakatikati.

Pophunzira za etiology ya ululu wa prepatellar pambuyo pa kukhomerera kwa intramedullary, njira ya tendon ya transpatellar inafanizidwa ndi njira ya parapatellar. Njira ya transpatellar tendon ikhoza kugwirizanitsidwa ndi chiwerengero chachikulu cha ululu wa mawondo pambuyo pa opaleshoni. Komabe, zomwe zikuyembekezeka kuti zidziwitse zachipatala sizinawonetse kusiyana kwakukulu pakati pa njira ya transpatellar tendon ndi njira ya parapatellar.

Kuchita bwino kwa kusankha kuchotsa kwa mkati kuti athetse kupweteka kwa prepatellar pambuyo pa tibial intramedullary nailing sikudziwika. Tikukulimbikitsani kuti kuchotsedwa kwa msomali wa intramedullary tibial kuganiziridwa ngati makina a etiology angadziwike, monga kukwera kwa msomali kapena phula lozungulira lolowera. Komabe, phindu la tibial intramedullary misomali kuchotsa odwala zizindikiro zimakhala zokayikitsa.

Ponena za ululu wa postoperative prepatellar, chifukwa cha ululu sichikhoza kuwonetsedwa momveka bwino mu phunziro loyamba lachipatala la intramedullary msomali fixation wa tibial msomali pa patella mu theka-wowonjezera udindo. Choncho, maphunziro akuluakulu a zachipatala omwe amatsatira nthawi yayitali ndi ofunikira kuti atsimikizire zotsatira za intramedullary misomali mu njira ya suprapatellar pa ululu wa postoperative prepatellar.

02.Kusayenda bwino pambuyo pa opaleshoni

Osteoarthritis ya post-traumatic imakhalabe vuto lalikulu pambuyo pochiza tibial stem fractures ndi intramedullary nailing. Maphunziro a biomechanical awonetsa kuti kusokonezeka kwa tibial kungayambitse kusintha kwakukulu kwa kukhudzana ndi kukhudzana ndi mawondo oyandikana nawo ndi mawondo.

Maphunziro a zachipatala omwe amayesa zotsatira zachipatala ndi zojambula za nthawi yayitali pambuyo pa kuphulika kwa tibial stem fracture apereka deta yotsutsana pa sequelae ya tibial malalignment, popanda ziganizo zomveka mpaka pano.

Malipoti a postoperative malalignment pambuyo pokhomerera intramedullary ya tibia amakhalabe ochepa, ndi chiwerengero chochepa cha milandu. Kuwonongeka kwa postoperative kumakhalabe vuto lodziwika bwino mu tibial intramedullary nailing, ndipo kuyesa kwa intraoperative kwa tibial rotation kumakhalabe kovuta. Mpaka pano, palibe kafukufuku wachipatala kapena njira yojambula yomwe yakhazikitsidwa ngati ndondomeko ya golidi yotsimikiziranso kuti tibial rotation. Makamaka, kupunduka kwa kasinthasintha wakunja kumawoneka ngati kofala kwambiri kuposa kusasinthika kwamkati. Kuwunika kwachipatala kuti awone kuwonongeka kwa postoperative kunanenedwa kukhala kolakwika ndipo kunawonetsa kusagwirizana kochepa ndi kuunika kwa CT.

Timakhulupirira kuti kusalongosoka kumakhalabe vuto la nthawi yayitali mu fractures ya tibial yomwe imachitidwa ndi intramedullary nailing of the tibia. Ngakhale kuti pali zidziwitso zotsutsana zokhudzana ndi mgwirizano pakati pa kusamvetsetsana ndi zotsatira zachipatala ndi zojambula, timalimbikitsa kuti madokotala opaleshoni ayenera kuyesetsa kuti akwaniritse ma fractures a anatomic kuti athe kuwongolera kusinthaku ndikupeza zotsatira zabwino.

五. Mapeto

Kutsekeka kosasunthika kowonjezereka kwa medullary intramedullary misomali kumakhalabe njira yochiritsira yosweka kwa tibial stem fractures. Malo olowera olondola amakhalabe mbali yofunika kwambiri ya opaleshoni. Njira ya suprapatellar mu malo otalikirapo amaonedwa kuti ndi njira yotetezeka komanso yothandiza, ndipo maphunziro amtsogolo ayenera kuwunikanso kuopsa ndi ubwino wa njirayi. Dokotala wochita maopaleshoni ayenera kudziwa njira zamakono zosinthira. Ngati kuyanjanitsa kwa anatomic fracture sikungatheke kupyolera mu njira yotsekedwa, njira zochepetsera zowonongeka ziyenera kuganiziridwa. Machiritso abwino opitilira 90 % amatha kupezeka ndi kukhomerera kokulirapo komanso kosakulitsidwa kwa intramedullary. Ngakhale machiritso abwino, odwala amakhalabe ndi zofooka za nthawi yayitali. Makamaka, kupweteka kwa prepatellar kumakhalabe kudandaula kofala pambuyo pa tibial intramedullary nailing. Kuonjezera apo, kusokonezeka pambuyo pa kukhazikika kwa tibial mkati kumakhalabe vuto lofala.

Maumboni

1.Study to Prespectively Evaluate Reamed Intramedullary Misomali kwa Odwala omwe ali ndi Tibial Fractures Ofufuza. Bhandari M, Guyatt G, Tornetta P, III, Schemitsch EH, Swiontkowski M, et al. Kuyesedwa kosasinthika kwa misomali yokhazikika komanso yosasinthika ya tibial shaft fractures. J Bone Joint Surg Am. 2008; 90:2567–2578. doi: 10.2106/JBJS.G.01694.

2.McQueen MM, Duckworth AD, Aitken SA, Sharma R, Court-Brown CM. Olosera a compartment syndrome pambuyo pa kuphulika kwa tibial. J Orthop Trauma. 2015. [Epub patsogolo pa kusindikizidwa].

3.Park S, Ahn J, Gee AO, Kuntz AF, Esterhai JL. Compartment syndrome mu tibial fractures. J Orthop Trauma. 2009; 23:514–518. doi: 10.1097/BOT.0b013e3181a2815a.

4.McQueen MM, Court-Brown CM. Kuwunika kwa zipinda mu tibial fractures. Chiwopsezo chambiri cha decompression. J Bone Joint Surg (Br) 1996; 78:99-104.

5.McQueen MM, Duckworth AD, Aitken SA, Court-Brown CM. Kuyerekeza kukhudzika ndi kutsimikizika kwa kuwunika kwamakampu a compartment kwa acute compartment syndrome. J Bone Joint Surg Am. 2013; 95:673–677. doi: 10.2106/JBJS.K.01731.

6.Whitesides TE, Jr, Haney TC, Morimoto K, Harada H. Miyezo ya mitsempha ya minofu monga chodziwikiratu chofunikira cha fasciotomy. Clin Orthop. 1975; 113:43–51. doi: 10.1097/00003086-197511000-00007.

7.Kakar S, Firoozabadi R, McKean J, Tornetta P., 3rd Diastolic blood pressure kwa odwala omwe ali ndi tibia fractures pansi pa anesthesia: zotsatira za matenda a compartment syndrome. J Orthop Trauma. 2007; 21:99-103. doi: 10.1097/BOT.0b013e318032c4f4.

8.Purnell GJ, Glass ER, Altman DT, Sciulli RL, Muffly MT, Altman GT. Zotsatira za pulogalamu ya computed tomography yowunika ma fractures a distal tibial shaft kuti awone fractures yosagwirizana ndi malleolar. J Trauma. 2011; 71:163-168. doi: 10.1097/TA.0b013e3181edb88f.

9.Buehler KC, Green J, Woll TS, Duwelius PJ. Njira yokhomerera intramedullary ya proximal third tibia fractures. J Orthop Trauma. 1997; 11:218–223. doi: 10.1097/00005131-199704000-00014.

10.McConnell T, Tornetta P, III, Tilzey J, Casey D. Tibial portal placement: radiographic correlate of the anatomic zone safe. J Orthop Trauma. 20

01; 15:207–209. doi: 10.1097/00005131-200103000-00010 .etc......