Ivunika rya Tibial, suprapatellar intramedullary tekinike yimisumari

Tekinike yimisumari yimbere yo kuvunika tibial: binyuze muri suprapatellar, inzira ya transarticular hamwe n ivi ryanyeganyega kuri 20-30 ° hamwe numuyoboro wihariye wo gukingira kurinda imiterere yimbere.

01.Tibial Intramedullary Nailing: kugera no guhuza, kubabara ivi imbere

Kubaga uburyo bwo kubaga imisumari ya tibial yamenetse ni ngombwa kugirango winjizemo umusumari winjiye unyuze aho winjirira neza, kugirango ugabanye ibyangiritse ku mavi yimbere yimbere, kandi bigere no kuvunika neza no kwinjiza imisumari.

Uburyo bwa kera bwo kuvunika tibial stem ni median infrapatellar cyangwa parapatellar. Nubwo ubu buryo bwerekanwe kuvunika hagati, valgus nyuma yo kubagwa, imbere, cyangwa syndesmotic deformations bikunze kugaragara mubice byinshi byegeranye.

Impamvu nyamukuru itera malaignment mu kuvunika kwa tibial hafi ni ubumuga buterwa no gukurura tendon ya quadriceps mugihe cyo guhindagurika kw'ivi hamwe namakimbirane yubukanishi hagati yimisumari na cortex yinyuma mugihe cyo kuyinjiza. Patella irinda kandi kwinjiza umusumari mu ndege ya sagittal (Ishusho 1a, b). Kubwibyo, ubundi buryo busanzwe bwo kwinjiza ingingo ni ukunyura hagati ya parapatellar yo hagati, bivamo kwinjiza imisumari hagati-na-kuruhande (Ishusho 1c na 2). Mugihe umusumari winjiye mu muyoboro winjiye kure cyane yo kuvunika, igice cyegeranye cyegamiye muri exostose (Ishusho 2). Hanyuma, impagarara zo kuruhuka imitsi yinyuma yimbere bigira uruhare runini kuri ectropion (Ishusho 3).

Igishushanyo 1 a, b Ukoresheje uburyo busanzwe bwa infrapatellar, patella irinda kwinjiza imisumari yumusumari, bikavamo ubumuga rusange bwo guhuza imbere ya apical sagittal ihuza na ectropion coronal alignment.c Guhuza imisumari yimbere byakozwe hakoreshejwe uburyo bwa parapatellar.

Igishushanyo 2 Kwegera aho winjirira unyuze hagati ya parapatellar iganisha kumurongo muto kugeza kwinjiza imisumari. Mugihe umusumari winjiye mu muyoboro wa medullary uri kure kuvunika (a), igice cyegeranye cyegamiye mumuriro (b)

Igishushanyo cya 3 Kuruhura impagarara yimitsi yinyuma (a) itanga uburyo bworoshye bwa ectopique (b)

Gufata tibia mumwanya mugari bifasha kwirinda ingorane zijyanye no guhindagurika kw'ivi rikomeye. Ubuhanga bwasobanuwe na Gelbke, Jakma n'abandi. muri 2010 kandi imaze kwamamara mumyaka yashize kuko gutera imisumari tibia muburyo bugororotse byoroshye byoroha kuvunika no guhinduranya. Fluoroscopy yoroshye mubuhanga gukora. Igihe cya fluoroscopi yo gutera imisumari ya suprapatellar byavuzwe ko ari kigufi cyane kuruta imisumari ya infrapatellar. Byongeye kandi, inguni yo kwinjiza imisumari (mu ndege ya sagittal) irasa cyane na axe ndende ya tibia hamwe nubu buryo kuruta no gutera imisumari ya infrapatellar; ibi birinda amakimbirane hagati yimisumari na cortex yinyuma, bityo bikagabanya kuvunika.

Nyuma yo kubagwa imbere y'amavi ni ikibazo gifatika. Ububabare bw'ivi bw'imbere bwagaragaye kuri 50-70% by'abarwayi bafite imvune, aho abarwayi 30% bonyine bafite ububabare nyuma yo gukuraho impera. Kugereranya inkovu zifitanye isano na patellar tendon hamwe na peteroli ya Hoffa byagereranijwe ko bishobora kuba intandaro yo kubabara ivi nyuma yo kubagwa. Byongeye kandi, uburyo bwa suprapatellar bwirinda gukomeretsa gakondo gutema ishami ryishami rya patellar ryumutima wa saphenous nervice, birinda kunanirwa kw'ivi ryimbere no kumva nabi (Ishusho 4). Kunyuza umusumari unyuze muri quadriceps, bityo ugasiga imitsi ya patellar idahwitse, bigaragara ko bigabanya cyane umuvuduko wububabare bwamavi nyuma yo kubagwa.

Igishushanyo cya 4 Isano iri hagati yimitsi ya saphenous nuburyo butandukanye bwo kubona imisumari ya tibialis obliqua

Bitewe nigisubizo cyiza cyo kuvunika hafi, ibimenyetso mubikorwa byubuvuzi byageze no kumeneka yose.

Ibibazo bishobora guterwa imisumari idasanzwe muburyo bwa suprapatellar:

- Ashobora gusiga imyanda mu ivi. Nyamara, uburambe bwubuvuzi hamwe na retrograde femorale imisumari ntabwo bwerekanye ingaruka mbi ngufi cyangwa ndende.

- Nigute uwatewe yakuweho nyuma yo kuvunika gukize? Nubwo bishoboka muburyo bwa tekiniki kuvanaho umusumari winjiye muburyo bwa suprapatellar, tekinike irasaba kandi abaganga benshi babaga bahitamo gukuramo umusumari winjiye muburyo bwa infrapatellar.

02.Ni ryari hakoreshwa umusumari wa suprapatellar intramedullary?

Ibyiza

- Ikibanza cyagutse cyamavi cyorohereza kuvunika no kugabanuka muguhuza imbaraga imitsi no kugumana mugihe cyo kwinjiza imisumari.

- Ibyago bike byo kwandura nyuma yibikorwa byavunitse byegeranye, ibice, hamwe na kure ugereranije nubuhanga gakondo

- Gutera imisumari byoroshye gukora

- Gutera imisumari birashoboka nka 'uburyo bumwe bwo kubaga '.

- Kugabanya igihe cya fluoroscopi

- Nta kwangirika kw'imitsi ya patellar no kutagaragaza ububabare bwo mu ivi nyuma yo gutera imisumari

- Byoroshye gukora muburyo bwamakipe menshi, kimwe na polytrauma.

Ibibi

- Ibyago byo kwangirika kw'amavi hamwe nizindi nyubako

- Kongera ibyago byo kwandura ivi

- Gukuraho ibimera bishobora gusaba ubundi buryo

Ibyerekana

- Ibice bidasanzwe-byavunitse bya tibia yegeranye (Ubwoko AO 41A)

- Ibice byoroshye byavunitse bya tibial diaphysis (andika AO 42A-C)

- Igice cya tibial diibhysis yamenetse (andika AO 42C)

- Ibidasanzwe-byoroheje kandi byoroshye intra-articular intera yaguye ya tibia ya kure (ubwoko AO 43A na C1)

- Ivi rireremba

Kurwanya

- Gustilo icyiciro cya 3C cyavunitse cya tibia kubera ibyago byinshi byo kwandura ingingo, nubwo ibyago byinshi byo kwandura ingingo bitigeze bivugwa mubice byafunguye.

- Amosozi yoroheje yoroheje, kwanduza cyangwa kwandura mukarere ka suprapatellar

- Prothèse idafite ivi (impande zombi)

- Gupfukama

- Amavi hyperextension> 20 °

- Kuvunika impande zombi za tibial plateau zirimo aho zinjirira imisumari ni ugereranije

- Gutera kubuza imisumari kwinjira

- Kuvunika impande zombi (kugereranya contraindication)

33. Uburyo bwo kubaga

Position Umwanya wumubiri hamwe nicyerekezo

Igishushanyo cya 5 Umurwayi aryamye hejuru kumeza ya radiyo ituma imyanya igabanuka. Igihimba cyavunitse gisigara kimanitse mu bwisanzure kandi umuzingo ugashyirwa munsi yivi (a) kugirango ugere kuri 10-30 ° yo guhindagurika. 

(b). C-ukuboko gushyirwa kuruhande. Ukuguru kutagize ingaruka kumanurwa 10-30 ° kuva kuri horizontal kugirango urebe neza amashusho mumwanya wanyuma.

Shakisha urushinge rwiburyo rwinjira

Igicapo 6 Ubu buryo bwaranzwe nigitereko cya patella, tibial tuberosity, na tibial cortex imbere. Uruhu rwa cm 2 z'uburebure rukozwe muri cm 1-1,5 hafi yumutwe wo hejuru wa patella. Ikirangantego cya quadriceps kigaragara kandi hagati ya longitudinal incision ikozwe mu cyerekezo cya fibre. Ikiruhuko cya suprapatellar kirakinguwe kandi intoki zo kubaga zinjira mu ivi kuva munsi ya patella kugirango harebwe uburyo bworoshye bwo kwinjira. Kwagura gahoro gahoro birashobora koroshya kugera kumavi. Kwinjiza retrator ya Langenbeck kugirango izamuke gato ya patella irashobora kandi kuzamura uburyo. Niba umwanya uhuriweho ari muto cyane kandi ibikoresho bigoye, umurongo wo hagati cyangwa uruhande rushyigikiwe urashobora guterwa hafi yacyo kugirango ugabanye igice cya patella kuruhande rumwe.

Kurinda karitsiye

Igicapo 7 Kurinda amakariso ya patellofemoral kwirinda imvune ziterwa no kubaga ni imwe mu ntego nyamukuru zuburyo bwo kubaga. Kubwibyo, amaboko yo gukingira agomba gukoreshwa mugihe cyibikoresho no gushyiramo imisumari.Ibikoresho byo kwinjira mu bice bitandukanye birimo imashini yinjizamo, amaboko yo hanze (yoroshye) n’imbere (ibyuma) birinda amaboko, ibyuma bya trocar, hamwe nuyobora insinga.b. Urushinge rwa trocar rwateranijwe hamwe nuburyo bwo gukingira no gushiramo.b Igikoresho cyo gushiraho hamwe nu mwobo uhumeka. Ipfunyika hejuru yumukono winjizamo irinda gutandukana kubwimpanuka inteko

Shyiramo umurongo ngenderwaho hanyuma uhindure umwanya

Igicapo 8a Inteko yintoki yinjizwa munsi ya patella ikoresheje patellofemorale yerekeza aho wifuza kwinjirira kuri tibia (Ishusho 9). Mubihe byinshi, patella izagenda gato hagati cyangwa kuruhande mugihe cyo kwinjiza ibikoresho. Urusenda ruri muri patellofemorale rusanzwe ruyobora urushinge rwa trocar kumwanya wukuri mu buryo bwikora.

Igishushanyo cya 8b Umwanya wemejwe mu ndege zombi ukoresheje fluoroscopi kandi ukosorwa aho bikenewe. Urushinge rwa trocar noneho rusimburwa nuyoboye icyerekezo, icyerekezo kinyura mu mwobo wo hagati wuyobora kandi inama yacyo ikinjizwa muri metafizike ya tibial hafi kugirango hamenyekane neza.

Igicapo 8c Iyo umurongo ngenderwaho uri mumwanya muto, umurongo wa kabiri urashobora gukoreshwa muguhindura bike mumwanya mwiza unyuze kumurongo wogusohora, kugeza kuri mm 4.3 mm Nkubundi buryo, birashobora koroha gutangirana nubuyobozi hanyuma ukabishyira muburyo budahwitse bwo kwinjira. Igikoresho cyo kwinjiza hamwe nuyobora noneho kiranyerera hejuru yubuyobozi.

Kwaguka kwa medulla oblongata

Igishushanyo 9a Gufungura umwobo wa medullary uhereye ahantu heza winjira ni intambwe ikomeye muburyo bwo kubaga. Mu ndege ya anteroposterior, iyi niyo ngingo yo hagati ya tibial spur kuruhande. Mu ndege ikurikira, aho yinjirira neza iherereye mu nzibacyuho hagati yubuso bwa arctular na cortex y'imbere.

Igishushanyo cya 9b Umwanya wukuri wuyobora ni umurongo wa tibial axis mu ndege ya anteroposterior kandi hafi ya parallel na cortex y'imbere ishoboka muburyo bwa projection. Ubuyobozi bukunda kugenda inyuma.

Igicapo 9c Mugihe mugihe pin cyangwa umusumari bidashobora kwinjizwamo neza, guhagarika umusumari cyangwa pin bifasha kuyobora umusumari muburyo bukwiye. 

Guhagarika imisumari bikoreshwa mugace kanini metafhyseal mugihe icyerekezo cyangwa umusumari bidashobora kuba byegeranye bigereranywa nigitereko kirekire cyamagufwa cyangwa mugihe kuvunika kutavunitse mumurongo umwe cyangwa byombi bigumye mugihe cyo kwinjiza imisumari.

Igicapo 10 Kuri iki cyiciro, birasabwa ko inteko yintoki yakomezwa kuri condyle yumugore ukoresheje insinga ya mm 3.2. Ibi birinda inteko gusohoka muri tibia.

Igicapo 11 12 mm ya hollow drill bit ishyirwa mumaboko yimbere yo gukingira no kumanuka unyuze kumuyobora kugeza kumagufa. Umuyoboro wa medullary ufungurwa no gucukura kugeza ubujyakuzimu bwa cm 8-10 hanyuma umurongo wanyuma wumupira winjizwa muri tibia yegeranye.

Kugabanya kuvunika

Igishushanyo 12a Kuri iki cyiciro, dusubiramo kuvunika.

Igicapo 12b Ukurikije aho ivunika riherereye hamwe na morphologie yaryo, ibikoresho bitandukanye byo kugabanya nka clips percutaneous clips, retractors, plaque uduce duto, hamwe nudukingirizo dushobora guhagarika kugirango bigerweho neza. Mugabanya kuvunika kwa tibial hafi, rimwe na rimwe ndetse hifashishijwe ubundi buryo bwo gushiramo, mbere yo gufungura umuyoboro wa medullary ukoresheje gucukura. Inkoni ya reaming yateye imbere kandi yinjizwa hagati ya tibial metafhysis ya kure. Nyuma yo guhindurwa, uburebure na diameter yumusumari biramenyekana. Nibiba ngombwa, wagura umuyoboro wa tibial kuri diameter wifuza usubiramo 0.5 mm yiyongera. Gufungura mumaboko yo gukingira birinda kweza no kunyunyuza imyanda iva mugihe cyo gusubiramo. Niba bishoboka, birasabwa ko hakoreshwa umusumari ufite byibura diameter ya mm 10. 5.0 mm Gufunga Bolt kubwubu bwoko bwimisumari irwanya kunanirwa kuruta mm 4.0 Gufunga Bolt ikoreshwa mumisumari myiza. Uburebure bw'imisumari isanzwe igenwa n'umutegetsi wa fluoroscopique.

Shyiramo umusumari

Igishushanyo cya 13a Kwinjiza imisumari ukoresheje inkoni ya reaming munsi ya fluoroscopi. Menya neza ko icyuma cyinjiza umusumari wa suprapatellar ari kirekire kurenza iyo umusumari wa infrapatellar kuko intera kuva kumubiri wuruhu kugeza aho tibial yinjira yinjira nayo ni ndende.

Igicapo 13b Nyamuneka menya ko kugoreka (Herzog curve) kumpera yimisumari yimbere yimisumari idashobora kwinjizwa mumaboko yimbere arinda ibyuma. Kubwibyo, imbere yo gukingira imbere igomba gukurwa mu nteko mbere yo gushyiramo umusumari (b; reba igice 'Amakosa, Akaga n’ibibazo '). Reba umwanya wanyuma wumusumari winjiye imbere-inyuma ninyuma. Kuraho inkoni ya reaming. Niba umusumari ukeneye gusimburwa, usige inkoni ya reaming mu mwanya hanyuma winjize umusumari mushya mu nkoni. Ibimenyetso bya mm 5 kumurongo winjiza byerekana ubujyakuzimu bwo kwinjiza muri tibia yegeranye (Ishusho 14). (Isanamu 14)

Gufunga kure kandi byegeranye

Igicapo 14a Ibishushanyo byegeranye kandi byitaruye bifunga biterwa nibiranga kuvunika. Gufunga hafi birashobora kugerwaho ukoresheje ukuboko kugamije. Gufunga intera ikorwa kubuntu cyangwa binyuze mugukoresha umurongo wa radiopaque. Bitabaye ibyo, umupira wanyuma urashobora gukoreshwa, urinda amagufwa gukura kumpera yegereye yimisumari yimbere kandi ikorohereza gukuraho nyuma. By'umwihariko, imisumari yinjijwe cyane biroroshye kuyikuramo iyo impera yanyuma yuburebure bukwiye ikoreshwa. Uburebure bwifuzwa bwumutwe wanyuma bupimwa no gushyira ikimenyetso kumurongo cyangwa mugushiramo umugozi uyobora ukoresheje ukuboko kugamije.

Igicapo 14b Isonga ryuyobora ryerekana umwanya wegeranye wimisumari yimbere. Umuyoboro uhuza ukuboko kugana ku musumari ugomba gukurwaho kugirango winjize umupira wanyuma. Impera yanyuma inyura muri barriel yimikorere. Igikoresho cyo gushiramo kiguma mu mwanya. Ibi bihuza ingofero yanyuma hamwe hejuru yumusumari winjiye kandi bikarinda kubura ivi. Kwinjiza umurongo ngenderwaho unyuze mumutwe wa barriel mumutwe wanyuma wumusumari nabyo bifasha kuyobora ingofero yanyuma kumyanya yabyo mumpera yegeranye yimisumari yimbere. Iyo gahunda irangiye, umuti wa saline sterile ugomba kwozwa kugirango woge imyanda isigaye.

44. Icyitonderwa

Icyitonderwa kubikorwa byo kubaga

- Mugihe cya osteoarthritis ibanziriza iyambere, kugendana patellar birashobora kubuza kwinjira hamwe. Gutemagura igice cyegereye igice cyo hagati cyangwa kuruhande rushyigikiwe kuva kuruhande rwagati byorohereza kwinjiza trocar pin.

- Prothèse idafite ivi ntabwo ari ukurwanya gukomeye kuri suprapatellar pinning. Menyako, ariko, ko bidashoboka kubona uburyo busanzwe bwo gutangiriraho uburyo bwo gutera imisumari hafi.

- Mu kuvunika hamwe no kwaguka kwa arctular, hashobora kwinjizwamo imigozi yinyongera kugirango ihagarike ibice byavunitse. Birasabwa ko iyo miyoboro ishyirwa mbere yo gushyiramo imisumari kugirango wirinde kwimuka kwa kabiri kuvunika.

Ibitekerezo byavunitse bya Tibia

Ivunika rya tibial proximal nimwe bigoye cyane kuvunika tibial kumisumari kandi bisaba ingingo zinjira neza (nkuko byasobanuwe haruguru). Ivunika rigomba kugabanywa mbere yo gutera imisumari kugirango irwanye imbaraga zose zihindura kandi bigerweho neza. Rimwe na rimwe, gushyira neza ingingo yanduye mu gice cyagutse kandi ukabona aho winjirira neza hanyuma ugashyira umusumari hamwe numuyoboro wa medullary mumashoka ya coronale na sagittal bizavamo guhuza neza tibia nyuma yo gutera imisumari.

Nubwo bimeze bityo ariko, mubihe byinshi, inzira zimwe zo kugabanya zirasabwa kubona no gukomeza kwimurwa gushimishije kwimvune. Niba umurongo wavunitse woroshye kandi ufite inguni, byoroheje byerekanwe gusubiramo clamps cyangwa gufatira hamwe, gushyirwaho muburyo butandukanye, birashobora gukoreshwa kugirango ubone no gukomeza gusubiramo mugihe cyo gutera imisumari. Niba clamp idahagije cyangwa indege yamenetse ntabwo yiha kwifata, amabyi cyangwa guhagarika imigozi birashobora gufasha kwirinda kwimuka no kwimuka (Ishusho 15). Iyi miyoboro ishyirwa inyuma yumwanya wimisumari wifuzaga kuruhande hanyuma ukareba kuruhande rwimisumari wifuzaga kuruhande rwinyuma. Gushyira neza iyi screw kugirango usubiremo neza birashobora kugorana.

Igishushanyo cya 15 Gufunga imigozi yashyizwe hanze yinzira yifuzwa yimbere imbere ninyuma (a) ninyuma yinzira yimisumari yifuza kuruhande (b) kurwanya imbaraga zo guhindura ibintu.

Ubundi buryo bukomeye cyane ni ugukosora by'agateganyo kuvunika mu mwanya wa anatomic (Ishusho 16). Mubisanzwe agace gato kabisa hamwe nibice bibiri cyangwa bitatu bifunga imiyoboro ya cortical bifata imvune yagabanutse mugihe cyo gutegura imiyoboro yumuzi no gushyiramo imisumari. Isahani izagenzura ibyimurwa byombi. Isahani igomba gusigara ahantu hose mugihe nta cyuho gihamye cyo gukumira igabanuka ryagabanutse bikunze kubaho nyuma yo gukuraho isahani. Isahani ifite umugozi umwe wa cortical ntabwo ikomeye kandi ntabwo izagira ingaruka kumiterere yumusumari. Tekinike yo gusubiramo isahani irashobora gukoreshwa haba kumeneka no gufunga.

Igicapo 16 Isahani ntoya ifunze ifite umugozi umwe wa cortical irashobora kuboneka kandi igakomeza muburyo bwa anatomic. Mu bihe byinshi, isahani igomba gusigara ahantu nyuma yo gutera imisumari. ubumuga bwa mbere bwa valgus bwo kuvunika hafi ya tibial. b Isahani ntoya yamenetse ifite umugozi umwe wa cortical ishyirwa muburyo bwo kubona no gukomeza kuvunika mugihe cyo gutera imisumari. c Isahani ntikurwaho nyuma yo gutera imisumari kuko itanga ituze ryinyongera

Kudahuza, Akaga n'ingorane

- Kwimura mu buryo budasanzwe bwo kurinda Sleeve birashobora kuviramo kwangirika kwa karitsiye hamwe n’imitsi yo mu mavi (Ishusho 17). Intoki irinda igomba kongera gushyirwamo byuzuye.

- Kugabanuka gahoro gahoro kurinda birashobora gukaza umurego reamer. Fluoroscopy ifasha kumenya ikibazo. Ongera uhindure amaboko arinda bizakemura ikibazo (Ishusho 18)

- Gufunga imisumari: Igiterwa gishobora guhinduka mumaboko yicyuma kumurongo wegeranye (Herzog curve). Kugirango ushyiremo imisumari ya nyuma, umuyoboro wicyuma ugomba gukurwaho, hasigara gusa amaboko yoroshye ya plastike yo hanze. Iyo umusumari ufashe, ugomba kongera gukurwaho burundu hanyuma ugaterwa ukongera gushiramo nyuma yo gukuramo urumogi rwicyuma ukoresheje urumogi rwa plastike gusa.

Igicapo 17 Gukuramo amaboko atarinze gukurikiranwa na fluoroscopique birashobora gukomeretsa ivi

Igicapo 18 Kwiyegereza cyangwa kugoreka impanuka yikingira birashobora kubangamira kuvanaho reamer, nkuko umutwe wa reamer ushobora guhagarara. b Igenzura rya fluoroscopique hamwe no gukosora guhuza kwemerera gukuraho umutwe wa reamer. c Umutwe wa reamer urashobora gukurwaho niba umutwe wa reamer udahari. d Umutwe wa reamer urashobora gukurwaho niba umutwe wa reamer udahari.

Reba

Hessmann MH, Buhl M, Finkemeier C, Khoury A, Mosheiff R, Blauth M. Suprapatellar imisumari yimvune za tibia. Koresha Orthop Traumatol. 2020 Ukwakira; 32 (5): 440-454.