Femoral Intramedullary Nailing - Nigute wahitamo ingingo nziza yo gushiramo?

Intangiriro

Iterambere ryo kuvura kuvunika kw'igitsina gore rishobora guhera mu myaka ya za 40 igihe Kuntscher yatangizaga uburyo bwo gufunga imisumari. Gukoresha imisumari yimbere (IMNs) mu kuvunika kwabagore byahindutse urwego rwubuvuzi mumyaka mike ishize, hamwe niterambere ryubu muri gutera imisumari imbere no gutera imbere mubuhanga bwo kubaga byatumye habaho kwiyongera gukomeye mu gukoresha imisumari ya femur.

Kuvura neza kuvunika kw'igitsina gore bikoreshwa gusa mu mubare muto cyane w'abarwayi bafite imiti igabanya ubukana bwa anesteziya no kubagwa, kandi inkingi nyamukuru yo kuvura ikomeza gukosorwa kubagwa. Kubijyanye no kuvura kubaga ibyo byavunitse, hari amahitamo menshi aboneka, harimo imisumari idasanzwe, gukosora amasahani, hamwe no gukosora hanze. Ugereranije nubundi buryo bwo kubaga, gutera imisumari ni uburyo hamwe nigipimo gito cyo kugorana nigipimo kinini cyo gukira kuvunika, kandi kigenda gikoreshwa cyane mubikorwa byubuvuzi.

Gusobanukirwa neza na anatomiya ya femur yegeranye, itangwa ryamaraso kumutwe wigitsina gore hamwe na anatomiya yimitsi yibibuno birashobora kongera cyane intsinzi yo gutera imisumari yimbere yo kuvunika kwumugore. Ibinyuranye, guhitamo aho byinjirira biterwa nibintu byinshi, harimo gushushanya imisumari yimbere, aho yavunitse, kuvunika, hamwe nimpamvu zabarwayi (urugero, polytrauma, gutwita, n'umubyibuho ukabije). Hatitawe ku kibanza cyinjira cyatoranijwe, kubona aho byinjirira ni ngombwa kugirango ugabanye kugabanuka bihagije mugihe winjizamo imisumari mugihe ugabanya ibyago byingutu.

Anatomy

1.Amaraso atanga kumutwe wumugore

Umutwe wigitsina gore wakiriye imitsi iva mumitsi 3 ikomeye. Umuyoboro wa rotateur femorale (ufite amashami 3-4), imiyoboro ya obturator, itanga uruziga ruzengurutse, hamwe na arteriire ya rotateur femorale (Igishusho 1), nayo itanga icyombo kizamuka kizamuka hejuru ya anastomose hamwe na arteri femorale femorale kandi igatanga akarere kanini ka trocanteric.

2.Anatomy yimitsi yibibuno

Iyo ukora imisumari yimbere yintoki, gusobanukirwa neza imitsi mugace gakikije rotor ningirakamaro kugirango wirinde gukomeretsa bitari ngombwa. Imitsi ya gluteus medius ikomoka kuri ilium ikarangirira kuruhande rwuruhande rwa trocanter nini, mugihe imitsi ya gluteus minimus nayo ikomoka kuri ilium ikanyura hejuru yinyuma yibibuno byikibuno kugirango irangire kuruhande rwinyuma ya trocanter nini (Ishusho 2 & 3). Iyi mitsi yombi ikora nk'inyongera yibibero hamwe na rotateur imbere yibibuno. Kubwibyo, kwangirika kwimitsi mugihe cyo gushyiramo imisumari ya paracentric femoral intramedullary imisumari bizavamo intege nke za adcuctor hamwe na Trendelenburg kugenda, bigira ingaruka mbi kumikurire yabarwayi nibisubizo.

Igishushanyo cya 2. Anatomy yimitsi ikikije ikibuno

Igishushanyo 3. Agace kegeranye imitsi yumugore

Iringaniza Umugore Wimisumari

Ubushakashatsi bwinshi buherutse gukorwa bwerekanye uburyo bwiza bwo kwinjira kumisumari ya paracrine. Amahitamo yinjira mumisumari arimo trocanter nini na pyriform fossa, buri kimwe gifite ibimenyetso byacyo hamwe nibibazo bifitanye isano (Imbonerahamwe 1).

Imbonerahamwe 1.Gutangiza ingingo ningaruka zishobora guterwa na paracrine na retrograde imisumari yumugore
variant	parallel intramedullary imisumari		retrograde intramedullary imisumari
	rotor	pyriform fossa (anatomy)
indege	Vertex ya trochanter nini kandi yerekana hagati ya cavit medullary	ihuriro rya trochanter nini nijosi ryumugore	umuhuza wa intercondylar fossa (anatomy)
indege ya sagittal (imibare.)	Umurongo uri hagati ya trocanter nini na centre ya marrow cavit ya femur	pyriform fossa (anatomy)	PCL 1,2 cm imbere yimbere yumugore utangirira, yerekana umwobo wa medullary.
Kumurika	Itsinda ryashimuse itsinda rihagarika gukomeretsa ingingo	Kubangamira itangwa ryamaraso kumutwe wigitsina gore no mu kibuno imitsi ya rotator yo hanze	Gukemura nabi bishobora kuganisha kuri PCL
PCL: ligamenti yimbere

1.Icyerekezo kinini cya rotor

Trochanter nini yasobanuwe nka trapezoidal bony protuberance yo hanze iri kuruhande rwuruhande rw ijosi ryigitsina gore, hejuru yacyo itanga umugereka wa gluteus medius na imitsi ya gluteus minimus y'imbere (Ishusho 2 na 3). Nubwo ibi ari akantu gato kerekana ibimenyetso, gutandukanya aho gutangirira neza mugihe ukora IMN yumugore bishobora kuba itandukaniro riri hagati yo kubona ibisubizo bishimishije cyangwa bibi mugihe uhanganye no kuvunika kwumugore.

Twihweje ubuvanganzo bwa none kubisobanuro byinjira byigitsina gore, twasanze habuze kubura ibimenyetso byerekana neza ibimenyetso byerekana imiterere ya rotor femorale IMN yinjira.Bharti nibindi. yasobanuye aho yinjirira kuva hejuru ya apical ya trocanter nini nkaho ari medial yerekeza mu cyuho cya medullary mu mwanya wa orthostatike, kandi nkikibanza cyo hagati ya trocanter nini ijyanye na centre yu mwobo wa medullary femorale mu mwanya wuruhande (Igicapo cya 4), kandi ubundi buryo bwo gusobanura icyerekezo kinini cyinjira hagati yinyuma yinyuma yinyuma yinyuma yinyuma yinyuma yinyuma yinyuma yinyuma yinyuma yinyuma yinyuma yinyuma yinyuma yinyuma yinyuma yinyuma yinyuma yinyuma yinyuma. rotor.Georgiadis n'abandi. yasobanuye ingingo yinshinge yinjira nkuruhande rwinyuma rwimbere ya apical isumba marike ya rotor.

FIGURE 4. Imikorere idasanzwe ya orthostatike hamwe nu mpande zombi zerekana ikibuno cyerekana ahantu heza hinjirira inkeragutabara zaba femorale imisumari yimisumari ya trocanter nini. '* ' yerekana aho imisumari yinjira.

Ubushakashatsi buherutse gukorwa mubuvanganzo bwerekanye ko apex ya trochanter nini aribwo buryo bwiza bwo gutangiriraho kubona umurongo wimbaraga nziza, kandi ko guhuza nabi bitewe nubumuga bwo guhinduka akenshi bibaho mugihe aho winjiye wimuriwe hejuru ya mm 2 kuruhande kuruhande rukomeye. Ubu bushakashatsi bwashimangiye kandi ko aho binjirira inyuma biganisha ku kwimura kure, mu gihe aho binjirira hagati hashobora gutuma igice cyo kuvunika cya kure cyimurwa inyuma. Ibinyuranye na byo, ubundi bushakashatsi bwerekanye ko mu kuvunika kw’umugore hagati y’imyanya ndangagitsina, umubare w’imisumari yatewe no gutera imisumari wari mwinshi cyane hamwe n’igitereko cyerekeranye n’uruhande rwimbere kuruta aho gifatira hafi y’impande n’inyuma.

Ikibanza kinini cyitwa trochanteric apex pinning point gikunze gukoreshwa mubarwayi bafite umubyibuho ukabije, kandi ubu buryo ntabwo busaba tekiniki, butanga igihe gito cyo gukora kandi ibyago bike byo guhura nibibazo kuruta pyriform fossa pinning point.

BIKORESHEJWE: Ibibazo bitangirana na nyuma yibikorwa bya femorale intramedullary imisumari hamwe ninzira nini ya trocanteric byaganiriweho mubitabo byinshi. Kimwe muri ibyo, ubusanzwe kijyanye nubuhanga bwo gutera imisumari, ni kuvunika kwa muganga. Mu kuvunika kwimyanya ndangagitsina, ingingo yinjira iherereye kuruhande no imbere imbere ya trocanter nini birashoboka cyane ko byaviramo kuvunika hagati aho kwinjirira hafi kuruhande.

Iyindi ngorane ifatika iterwa no gukomeretsa byoroheje-tissue, cyane cyane kumashami ya rotator yo hagati ya femorale femorale hamwe n imitsi ya adductor, ariko izi nkomere ntizikunze kugaragara ugereranije na pyriform fossa yinjira. Byongeye kandi, indwara ya ischemic necrosis yumutwe wigitsina gore hamwe nisonga rya trochanter nini kuko aho binjirira batekereza ko ari hasi cyane, ubushakashatsi buvuga ko ari 0.3%.

Urebye igihe cyo gukorana hamwe na fluoroscopique, igihe cyo gukora cyari iminota 90.7 kumwanya munini winjira muri trochanteric ugereranije niminota 112.7 kumatsinda ya fossa yinjira mumatsinda, mugihe fluoroscopique yari amasegonda 5.88 kumurwi munini winjira muri trocanteric hamwe namasegonda 10.08 kumurwi winjira mumasaro ya fossa.

Kumenyekanisha abarwayi nabyo byari ikintu cyingenzi mugihe cyo gufata umwanzuro winjira mumisumari yinjira, kuko gukira hakiri kare (nkuko byagaragajwe nikizamini cyintebe yintebe hamwe nigihe cyo gupima igihe) byari byiza cyane kubarwayi mumezi 6 nyuma yo kubagwa kugirango binjiremo trocanteric nini ugereranije na pyriform fossa yinjira, ariko iri tandukaniro ntabwo ryari rifite mumezi 12 nyuma yubuvuzi. Nubwo uburyo bunini bwo kugera kuri trocanteric busanzwe bujyanye no kwambura ingirabuzimafatizo zoroheje bitewe n’aho biherereye, birashobora gukomeretsa itsinda ry’imitsi yashimuse, nkuko byagaragajwe na Er tut n'abandi. Basanze kuringaniza imbaraga hamwe no gushimuta ikibuno byagabanutse kubarwayi bafite urumogi runini rwinjira muri trochanteric ugereranije no kugenzura neza. Byongeye kandi, ubushakashatsi bwabo bwerekanye ko igabanuka ryinshi ryimbaraga zashimusi yibibuno, flexors na rotateur imbere / hanze ugereranije kuruhande rudakorwa.

2. Pearly fossa yinjira

Fossa yimitsi ya pyriformis nikimenyetso cyingenzi kidasanzwe cyerekanwe nkimwe mumyanya yinjira mumisumari ya paracentesis femoral intramedullary.Mu bushakashatsi bwabo bwa autopsie cadaveric, Lakhwani nibindi. yavuze ko fossa yimitsi ya pyriformis itari ishusho ya 'pear ' cyangwa se imitsi ya pyriformis. Imitsi ifata ahantu hato hejuru yisonga rya trochanter nini, mugihe pyriform fossa ni depression kuruhande rwagati rwumutwe munini kandi ni umugereka wimitsi ya carpi radialis brevis imitsi. Abanditsi banzuye bavuga ko imitsi ya pyriform na pyriform fossa ari ibintu bibiri bitandukanye kandi ko icyitwa pyriform fossa kigomba kwitwa 'rotor ' cyangwa fossa ya 'occlusal ' kugirango bisobanuke kandi bikosorwe neza. Basabye ko nyuma yo kwiga cis-femoral Basabye ko ijambo ryumwimerere 'rotor fossa ' ryongera gusubirwamo mubitabo aho kuba 'pyriform fossa ' nyuma yo kwiga ijambo ryijambo ryinjira muri parafemorale. Nubwo ingingo zizi nyigisho zombi zubahwa cyane, kugirango byoroshye gusobanurwa no gukumira urujijo hamwe nini nini yinjira muri trochanteric, tuzakomeza kwerekeza kuriyi ngingo yinjira nka pyriform fossa yinjira.

Ubushakashatsi bwinshi mubuvanganzo bwa none busobanura neza aho bwinjirira bwa pearl fossa kumisumari yimbere yumugore.Georgiadis nibindi. sobanura pearly fossa aho yinjirira nk'ahantu ho gufatira imitsi ya carpi radialis brevis imitsi yo kwiheba munsi yijosi ryumugore (Ishusho 5). Abanditsi bashimangiye kandi ko aho binjirira biri kure cyane cyangwa imbere cyane bishobora kongera ibyago byo kuvunika ijosi ry’umugore, kandi iyo aho binjirira hasigaye inyuma cyane, hashobora kubaho ibyago byinshi byo kwandura ischemic necrosis, bikaba byinshi ku barwayi bangavu.

Igicapo 5.Ibikorwa byimbere yibibuno byerekana ikibanza cyiza cyo kwinjiramo pyriform fossa retrograde femoral intramedullary imisumari. '* ' Yerekana intangiriro yimisumari.

Harper n'abandi. yasohoye ubushakashatsi bwakozwe nitsinda 14 ryabantu cadaveric femurs yabantu mumwaka wa 1987 aho basuzumaga aho pin yayoboye pin hamwe n’ahantu hasohokera imisumari yimbere yatangijwe kure kandi hafi muburyo bwa retrograde uhereye kumurongo wa intercondylar ya femur. Bashoje bavuga ko aho kwinjiza imisumari ya pyriformis inkeragutabara ziherereye mu masangano ya trochanter nini nijosi ryigitsina gore, imbere gato gato ya pyriformis occulta. Ikibanza cyashyizwemo cyongeye gushimangirwa na Gausepohl nabandi. Muyindi nyigo ya cadaveric, bahinduye ahantu heza ho kwinjirira imisumari ya femorale imbere yumusozo wo hagati ya trocanter nini hejuru ya pyriformis. Byongeye kandi, mubushakashatsi bwa cadaveric na Labronici nabandi. fossa yimitsi ya pyriformis yasobanuwe nkakarere kameze nkamapera yumucyo wahuriranye nu murongo wo hagati wigitereko cyimyanya ndangagitsina mu ndege ya coronale.

Ahantu ho kugera kuri pyriform fossa hari ibibi byihariye kuko biragoye muburyo bwa tekinike ugereranije n’ahantu hanini ho kugera, cyane cyane ku barwayi bafite umubyibuho ukabije. Mubyongeyeho, urubuga rwiza rwinjirwamo rwa pear-shusho ya fossa inshinge yinjira ni agace gato, bigatuma bigorana cyane. Kurugero, aho gutangirira cyane kurenza ijosi ryigitsina gore bizaviramo guhangayika bikabije kandi byongere ibyago byo guturika imbere, cyane cyane iyo intangiriro irenze mm 6 imbere ya fossa. Byongeye kandi, itandukaniro rya morphologique rishobora kubangamira urubuga rwukuri rwinjira, cyane cyane iyo rotate ngufi yo hanze ari nini cyangwa rotor irasohoka, biganisha ku rubuga rwinjira ruri hagati cyane kandi rushobora kuvunika ijosi ryumugore.

BIKORESHEJWE: Mugereranije ibibanza 38 binini byinjira muri trochanteric hamwe na 53 byinjira mumasaro ya fossa yinjira mumisumari ya femoral intramedullary, Ricci nabandi basanze itsinda rya pearly fossa rifite igihe kinini cyo gukora 30% nigihe kinini cya fluoroscopi. Ibyavuye mu bushakashatsi byemejwe na Bhatti n'abandi. iyo ugereranije ingingo 2 zinjira inshinge.

Kubyerekeranye no gukomeretsa byoroheje-tissue, hashobora kubaho ibyago byinshi byo gukomeretsa byoroheje-tissue ku kayira ka pyriformis ugereranije na neuromuscular interosseous interosseous neuromuscular aho yinjira inshinge nini ya trochanteric. Dora n'abandi. yasuzumye femurs 16 ikuze ya cadaveric kubwo gukomeretsa ingirabuzimafatizo zoroheje imitsi ya pyriformis na rotor yinjira. Basanze ko nubwo pyriformis fossa yari nziza ya geometrike, yangije cyane kwangirika kwamaraso kumutwe wigitsina gore no mumitsi hamwe nimitsi. Ibyavuye mu bushakashatsi byashimangiwe n’ubushakashatsi bwa cadaveric bwakozwe na Ansari Moin n'abandi. OMS nayo yagereranije ingingo ebyiri zinjira. Bavuze ko gutunganya imisumari imbere bitangirira ku mitsi ya pyriformis byashobokaga kwangiza abashimusi ba kibuno hamwe na rotateur yo hanze. Byongeye kandi, kwangirika kwimitsi yo hagati ya femorale femorale yabonetse mubihe byose (Imbonerahamwe 2).

Imbonerahamwe 2. Incamake yimvune zoroheje zumubiri ahantu hatandukanye
variant	Pyriform fossa yinjira (n = 5)	Ingingo nini yo kugaburira rotor (n = 5)
imyenda yoroshye
gluteus medius imitsi (anatomy)	5	1
gluteus medius tendon	0	4
imvune
gluteus minimus (anatomy)	3	0
imitsi ya pyriformis (hejuru yumugongo)	3	3
obturator internus (anatomy)	1	0
imitsi ya latissimus dorsi (anatomy)	3	0
Imiyoboro y'amaraso hamwe na capsules
MFCA Amashami Yimbitse	4	0
Ishami rya MFCA	4	0
capicular capsule (yingingo nkivi muri anatomy)	1	0
MFCA: imiyoboro yo hagati ya medial femorale.

Vuba aha, Bharti n'abandi. yakoze ubushakashatsi ku ngaruka ziterwa no gutera imisumari femorale ku ntera nini yinjira muri trochanteric yinjira hamwe na pearly fossa yinjira hanyuma asanga ingaruka ziterwa ningaruka nkigipimo cyo gukira kuvunika hanyuma abivuga muri make kuburyo bukurikira (Imbonerahamwe 3).

Imbonerahamwe 3
ingorane	Piriformis sinus inshinge	Ingingo nini yo kwinjiza ingingo
Wanduye	6.7	3.3
Malunion	20	13.3
Gutinda gukira	20	13.3
Kugenda kw'ibibuno bigarukira	20	33.3
Kugenda kw'ivi bigarukira	6.7	6.7
Uburebure bw'amaguru butandukanye	13.3	20
Umurizo wumurizo ugaragara hejuru yamagufwa	13.3	20
Intraoperative femorale ijosi	10	0
Kumeneka gukomeye	0	3.4
Femoral head necrosis	6.7	0

Retrograde femoral intramedullary imisumari

Kugena aho byinjirira kugirango retrograde femorale intramedullary imisumari bizafasha kugera kugarura uburyo bwiza bwo kuvunika neza, uburebure, no kuzunguruka mugihe hagabanijwe kwangirika kwa karitsiye, ligamenti yimbere (ACL), ligamenti yimbere (ACL), no gukomeretsa imyenda yoroheje (Imbonerahamwe 1). Vuba aha, abantu benshi bashishikajwe no gutera imisumari ya retrograde femorale intramedullary hagamijwe kugabanya ingorane zijyanye no gutera imisumari ya paracromial, harimo ububabare bwo mu kibuno, ossification ya heterotopique, intege nke za adductor, hamwe nudukoko twa pudendal nudusimba twa pudendal dufatwa nkibitero byoroheje mugihe ugereranije no kugabanya ibice no gufunga ibice byumugore kugirango bikosorwe imbere. Byongeye kandi, ibimenyetso biheruka kwerekana byerekana ko iyo iyi misumari ya retrograde ingero zingana neza, imisumari yo gufunga yegeranye ntishobora gukenerwa. Nta tandukanyirizo ryibipimo byo gukira, igihe cyo gukira, cyangwa ibyavuzwe n’abarwayi hagati ya Meccariello n'abandi. na Bisaccia n'abandi. mukuvura kure ya kimwe cya gatatu cyigice cyigitsina gore ukoresheje gufunga no gufungura retrograde imisumari yimbere. Rero, ikoreshwa rya retrograde femorale imisumari ryamenyekanye kandi ryemerwa na benshi.

Ibisobanuro byinshi byerekana uburyo bwiza bwo kwinjira kuri retrograde femoral intramedullary imisumari urashobora kubisanga mubitabo. Ubushakashatsi bwinshi bwerekana ahantu heza hinjirira imisumari ya retrograde femorale nka 1.2 imbere yinkomoko yumugore winkomoko yinyuma ya ligamenti

cm (ijyanye na cavit medullary) hamwe hagati ya fossa ya intercondylar (Ishusho 6).

FIGURE 6. Intooperative orthostatike nu mpande zombi zivi zerekana ivi ryerekana ahantu heza hinjirira retrograde femoral intramedullary umusumari. '* ' yerekana imisumari yimbere.

Nubwo nta kimenyetso na kimwe cyerekana retrograde femoral intramedullary imisumari, ibimenyetso byinshi bifitanye isano byasobanuwe. Muri byo harimo abarwayi ba polytrauma, abarwayi bafite umubyibuho ukabije, abarwayi batwite, kuvunika kw'ibiti byombi, kuvunika uruti rw'umugore no kuvunika acetabular / pelvic cyangwa kuvunika ijosi ry'umugore, hamwe no kuvunika kw'igitsina gore no kuvunika. Ibyinshi muri ibyo bimenyetso bifitanye isano no koroshya imyanya y’abarwayi no kwirinda ibikomere byinshi byo kubaga hafi.

Ku rundi ruhande, ibivuguruzanya rwose kuri retrograde femoral intramedullary imisumari harimo kubuza umuyoboro wa retrograde intramedullary umuyoboro wagumishijwe hamwe no kuvunika kumugongo wa kure. Kwanduza bifitanye isano ni kuvunika biherereye muri cm 5 za trocanter ntoya, ingorane zo kugera ahantu heza hinjirira bitewe no guhindukirira ivi bitarenze dogere 45, kwandura ivi mbere bishobora gutera ibyago byo gukwirakwira ku gitsina gore, ibikomere byoroheje-tissue bikikije ivi, hamwe no kuvunika imbere mu mitsi ya pola ntoya na pole ikabije.

Ingorane: Byinshi mubibazo bya retrograde femorale imisumari bifitanye isano no gufata nabi, cyane cyane gushyira nabi aho winjirira. Mu ndege ya sagittal, ingingo yinjira imbere izavamo ibisobanuro byavunitse inyuma, kwangirika kwinyuma, kandi birashoboka ko imisumari yatewe kuri patella mugihe ivi ryoroshye. Ku rundi ruhande, niba aho binjirira hashyizwe mu buryo budakwiye mu cyerekezo cyinyuma, ibi birashobora kuvamo ibyago byinshi byo gukomeretsa inkomoko yimbere yimbere hamwe no kwimura imbere yikibanza cyavunitse.

Hutchinson n'abandi. yasobanuye ingorane zijyanye na coronale yindege idakwiye. Basanze aho byinjira byinjira cyane byavuyemo ubumuga bwinyuma hamwe nubusobanuro bwavunitse nyuma, mugihe iyindi irenze urugero byaviriyemo ubumuga bwo hagati hamwe nubusobanuro bwo hagati.Sanders nibindi. yatangaje ko guhitamo aho bitangirira hagati ya cm 2 cyangwa zirenga kuruhande rwa mediya byaviriyemo kuvunika hagati ya cortical medial malunite kubera umwanya wa isthmic yunamye inyuma yo kuvunika bigatuma kugabanuka kwinyuma.

Izindi ngorane zijyanye na retrograde femoral abayoboke bakomeretsa imisumari harimo kubabara ivi, gukomera, osifisiyose ya heterotopique, hamwe no kuvamo umubiri imbere.

Umwanzuro

Nubwo buri tekinike yo gutera imisumari ifite icyerekezo kimwe, guhitamo uburyo bwo gutera imisumari imbere yo gukoresha mu kuvura imvune z’igitsina gore akenshi biterwa no kubaga abaganga. Iyo ukora imisumari yimbere yintoki, kubona aho winjirira neza kubwoko bwimisumari ikoreshwa mugukosora birasabwa kugirango bigerweho neza. Ubumenyi bwa anatomiya yaho hamwe nibikorwa byo gufata amashusho bizafasha kubaga gukora tekiniki ihagije mugihe hagabanijwe ingaruka ziterwa nibibazo. Byongeye kandi, muburyo bwo gutera imisumari, kubungabunga kugabanuka nikintu gikomeye mukurinda malunion na malunion cyangwa kudahuza kuvunika.