5 intramedullary chipikiri application misimboti uye maitiro ekuvhiya!

Nheyo dzekutanga dze intramedullary nailing

1. Nhoroondo ye intramedullary nailing

Muna 1910, Lilienthal aluminium intramedullary misumari yakashandiswa kurapa femoral shaft fractures.

Muna 1913, Schone akashandisa sirivheri intramedullary mbambo kurapa forearm kuputsika. 

Kuntscher (1900-1972) akaita zvipo zvikuru kune intramedullary nail fixation. 

Ma1960 nema1970 yaive nguva yekukurumidza kukura kwezvipikiri zve intramedullary. 

nyika yangu yanga ichivashandisa muhuwandu kubva kuma1990.

2. Kuzarura kuderedza uye kuderedza kuvharwa

1. Kuputsika kwemakumbo kunogona kuvhiyiwa kuderedzwa pasi pekuona kwakananga kana kuvharwa pasi pe X-ray monitoring.

2. Kuvhura kudzikisa kutsemuka kutyora nguva yekurapa yakati rebei, intraoperative kubuda ropa kwakawanda, uye kuvhurika kuderedzwa kunowedzera kuparadza kugovera kweropa kusvika kumagumo ekutyoka.

3. Inokurudzirwa kushandisa kuderedzwa kwekuvhara zvakanyanya sezvinobvira. A traction reducer inogona kushandiswa, kana diki incision inogona kuitwa pane yakatyoka ndege kuti iongorore uye ideredze, nekudaro ichideredza kupindira kweropa kusvika kumagumo ekutyoka.

4. Nokuda kwekukundikana kwekudzikisa kuvharwa, chidimbu chepfupa chinoputika kana kuboora mazamu akapoteredza, uye zvimedu zvakaputsika zvakaputsika, kuvhiyiwa kuzarura kuderedza kunogona kushandiswa.

3. Kugadzirisa nzira ye intramedullary chipikiri

1. Nzira ye intramedullary nail internal fixation is symmetrical central internal splint fixation.

2. Kugadziriswa kwekuputsika ne intramedullary nail ndiko kunetseka-kugovera kugadzirisa, kwete kushungurudza-kudzivirira kugadzirisa, iyo inobatsira pakuumbwa kwe callus.

3. Kugadziriswa kwepakati kunonyanya kukosha kune cortical kunze kwekugadzirisa, iyo inogona kuderedza simba rechisimba, kuderedza chiitiko che valgus angulation uye mukati mekugadzirisa kukanganisa.

4. Intramedullary nail fixation inopa hwaro hwekuvharwa kuderedzwa kana kushoma kuvhura kuderedzwa.

4.Zvakanakira zve intramedullary misumari

1. Zvinetso zvishoma

2. Yakawedzerwa chiyero chezviratidzo zvekuvhiya

3. Kugadzirisa kwakasimba

4. Early joint function training

5. Kutakura uremu hwepakutanga

6. Inogona kushandiswa pamwe chete nemamwe kugadziriswa kwemukati

Basic Types uye Techniques

1. Kuvhara uye kusavhara intramedullary misumari

2. Dynamic uye static kukiya intramedullary misumari

3. Medullary kuwedzera uye kwete-medullary kugadzirisa maitiro

4. Kuvhura uye kuvharwa kugadzirisa maitiro

Kupindirana uye kusapindirana

Zvipikiri zvakajairika zve intramedullary zvine kugadzikana kweaxial uye kuderera kwesimba rekudzoreredza, asi zvine imwe elasticity uye inogona kupora mushure mekutsvedza, zvichikonzera zvishoma chete intrabone kutsvedza.

Inopindirana intramedullary misumari ine zviri nani anti-kutenderera uye anti-compression mhedzisiro, yakanaka kugadzirisa kugadzikana, uye inowirirana nemusimboti webiological fixation. Izvo zvinoshandiswa zvakanyanya mumapfupa marefu emakumbo. Kunyanya kune akawanda-segment uye comminuted fractures, vane kugadzikana kuri nani pane zvakajairwa intramedullary zvipikiri.

Dynamization ye static fixation

Static kukiya intramedullary zvipikiri zvinoburitsa kushoma kwekunetseka masking uye parizvino vari kunyanya kusimudzirwa kune isiri-yekuita chiitiko che dynamization.

Nokuda kwekutyoka kusina kupora pamwedzi mitanhatu kusvika ku8 mushure mekuvhiyiwa, in situ bone grafting kana kutsiva yakawedzera intramedullary misumari ine dynamization inowanzoshandiswa.

Dynamization inogona kushandiswa senzira yekusimudzira kuporeswa kwekutyoka. Hazvikurudzirwe nguva nenguva nekuti zvinogona kutungamira mukupfupika kwemakumbo uye kuremara kwekutenderera.

Kuwedzera kwemwongo uye kusawedzera mwongo

Kuwedzera kwemwongo kunogona kuisa intramedullary zvipikiri zvine dhayamita yakakura uye simba rakakura, izvo zvinobatsira kudzidziswa kwekutanga kushanda uye kuderedza mwero wezvipikiri zvakatyoka.

Kuwedzera kwemwongo kunogona kuburitsa huwandu hukuru hwemapfupa emapfupa ane osteoinductive effect, iyo inobatsira kupora kuporeswa.

Kuwedzera kwemwongo kunokuvadza kugoverwa kweropa kwemidziyo inovaka muviri uye endosteal membrane, asi tsinga dzeropa dzinogona kuvandudzwa pamwe negomba re intramedullary mbambo. Kuwedzera kwemwongo kunogonawo kuwedzera kutenderera kweropa mumhasuru dzakapfava dzakatenderedza, nekudaro zvichikurudzira kuporeswa kwekutyoka.

Kuwedzera kwemwongo kunowedzera mukana wehutachiona uye embolism, uye inofanira kushandiswa nekuchenjerera kune yakavhurika kuputsika, kukuvara kwakawanda, uye kukuvara kwakaoma.

Zvakanakira zvekuwedzera kwe medullary

① Mushure mekuwedzera kwemedullary, nzvimbo yekubatana pakati pe intramedullary mbambo uye pfupa inowedzera, iyo inovandudza kugadzikana kwekugadzirisa. 

② Mushure mekuwedzera kwemedullary, yakakura dhayamita intramedullary chipikiri inogona kushandiswa, iyo inowedzera simba re intramedullary chipikiri uye inoderedza mwero wezvipikiri zvakaputsika. 

③ Marara emapfupa mushure mekuwedzera kwemedullary anogona kukonzera kuumbwa kwemapfupa matsva, izvo zvinoita kuti kuputsika kupora.

Kuenzaniswa nemedullary yekuwedzera intramedullary misumari, isina-yakawedzera intramedullary misumari ine zvinotevera zvakanakira.

① Inguva pfupi yekuvhiya uye kubuda ropa kushoma. 

② Kukanganisa kushoma ne endosteal kubuda kweropa muzviitiko zvine kukuvara kwakanyanya kwetishu.

Kushandiswa kwe intramedullary chipikiri

Humeral inopindirana intramedullary nail

Zviratidzo zvehumeral misumari

Zviratidzo zvehumeral interlocking intramedullary misumari mukurapa humeral shaft fractures ndezvi: fractures nevascular and nerve damage, kukuvadzwa kwakawanda, kuputsika kusina kugadzikana, pathological fractures, uye proximal humeral fractures.

Rudzi runogona kugadziriswa runobva pa2cm pazasi pemusoro wehumeral kusvika pa3cm pamusoro peolecranon fossa. Iwe unogona kusarudza kuigadzirisa kubva papfudzi neantegrade intramedullary nail kana kubva pagokora ine retrograde mbambo.

Humeral mbambo

Nzira dzekuvhiya dzekugadzirisa humeral shaft fractures ndeyekugadzirisa kweplate uye intramedullary nail fixation.

Plate fixation ine simba rinopesana-kutenderera uye rinopesana-kupeta uye rakanyatsogadziriswa, asi kuvhiyiwa kwekuvhiya kwakakura, mukana wehutachiona wakakwirira, uye radial nerve inokuvadza nyore nyore.

Mazuva ano humeral interlocking uye kuzvivharira zvipikiri zvinokunda kukanganisa kwezvipikiri zvakajairwa intramedullary senge axial instability, kutadza kutenderera kwekudzora, uye kudikanwa kwekuwedzera kugadzirisa, kuitira kuti kuputsika kugadziriswe kwakasimba, kurasikirwa kweropa kuri kudiki, kupfava kwenyama kuduku, uye medullary yekuwedzera yakaenzana neyokuremerwa kwepfupa, kushambadza kwekutanga kunoonekwa, kushambadza kwekutanga kunoonekwa. kutanga mushure mekuvhiyiwa.

Femoral interlocking intramedullary nail

Zviratidzo zvezvipikiri zvinopindirana zvechikadzi

Mhando dzose dzekuputsika 2cm pasi pe trochanteric vertebra uye kupfuura 9cm kubva pamabvi akabatanidzwa.

Kuputsika kwekare kwechikamu chepakati chefemoral shaft.

Varwere vane kukundikana kweplate mukati mekugadzirisa.

Zvinoumba femoral interlocking chipikiri

Mechanical zvakanakira

Ruoko rwesimba rwechikadzi runopindirana intramedullary mbambo yekugadzirisa kuputsika kwakareba kupfuura iyo yesimbi mahwendefa, uye simba rinogoverwa zvakaenzana papakati pepakati pefupa rose, izvo zvisiri nyore kukotama uye kukanganisa.

Zvipikiri zvekuvhara pamagumo ose e-intramedullary nail inoita kuti pfupa rive rakazara kubva kumusoro kusvika pasi, uye zvipikiri zvekuvhara pamagumo ekupedzisira zvinogona kuderedza ruoko rwe torque ye intramedullary chipikiri mubhonzo, kudzivirira kupfupika uye kutenderera, uye kuwana kugadzikana kwakanyanya uye kusimba kwekugadzirisa kuputsika.

Gamma Interlocking Intramedullary Nail

Gamma chipikiri zviratidzo

Inoshanda kune akasiyana marudzi e peritrochanteric fractures, kunyanya subtrochanteric fractures.

Yakawedzerwa Gamma chipikiri (rekuvakazve chipikiri) zviratidzo

high subtrochanteric fractures, trochanteric yakasanganiswa nefemoral shaft fractures.

Zvakanakira Gamma chipikiri

Yakagadzirwa nekubatanidza sliding hip screw ne intramedullary nail teknolojia, mbambo huru iri pedyo nemukati me medullary cavity pane simba rehudyu ndiro, saka Gamma nail inofambisa uremu hwemurwere pedyo ne calcar yemukadzi pane simba rehudyu rinoshanduka, richiwedzera simba remagetsi rekuisa. Kune subtrochanteric fractures inosanganisira medial cortical comminution, iyo Gamma chipikiri inodzivirira kudiwa kwekuputsika anatomy kuvaka, saka inobatsira kune intertrochanteric fractures kana subtrochanteric fractures.

Retrograde intramedullary femoral nailing

Zviratidzo zve retrograde femoral misumari

Inonyanya kushandiswa kune supracondylar femoral fractures, kusanganisira supracondylar comminuted fractures uye intercondylar 'T' uye 'Y' comminuted fractures inosanganisira articular surface.

Inogonawo kushandiswa kune femoral fractures pasi pe isthmus ye femur.

Femoral shaft, supracondylar femoral, uye intercondylar fractures mukati me20CM kubva pamabvi akabatanidzwa.

Avo vakatadza kugadzirisa ndiro.

Hunhu hweretrograde femoral nailing

Supracondylar femoral fracture ndeyekuputsika kwakakomba nekuoma kwekutanga, kuderedza uye kechipiri, kugadzirisa kwakasimba kwemukati. Pane chiitiko chepamusoro chematambudziko akadai sekutyoka kusiri mubatanidzwa uye kunonoka kupora.

Retrograde interlocking intramedullary nailing inzira inowanzoshandiswa kurapa distal femur fracture mumakore achangopfuura, iyo ine yakanaka mechanical kugadzikana, inogona kunyatso kudzora posterior displacement uye rotational displacement ye distal kupera kwekutyoka, uye inobatsira mukutanga kwekubatana.

Supracondylar yakasanganiswa femoral stem fracture inogadziriswa nekurebesa supracondylar intramedullary nailing, iyo inogadzirisa dambudziko rakaoma kugadziriswa nekuvharira intramedullary nailing yefemur. Icho chiridzwa chiri nyore kushandisa, chakarurama mukugadzirisa, chakavimbika mukugadzirisa, uye murwere anogona kuita maitiro ekutanga ekushanda emabvi mushure mekuvhiyiwa.

Tibial inopindirana intramedullary misumari

Zviratidzo zvetibial nailing

Kuputsika kwakagadzikana pakati pe 1/3 yetibia: kuputika kwepakati, kupfupika kwemaoblique fractures, pseudarthrosis.

Kuputsika kusingagadziki mukati me60% yehurefu hwepakati tibia: kuputsika pedyo nemetaphysis, kureba kwakaputika kuputika, segmental fractures, comminuted fractures, fractures nemapfupa akaremara.

Hunhu hwetibial nailing

Inopindirana intramedullary nailing yetibia inonyanya kushandiswa kune mid tibia fractures.

Kunyange zvazvo inogona kushandiswawo kune proximal uye distal tibia fractures, chiyero chekutambudzika chakakwirira, malunion inowanzoitika kakawanda, kupera kwekuputika kune ≧1cm yekufamba mu 1/2 yematambudziko, uye 1/4 yekugadzirisa inokundikana.

Zvinyorwa zvakashuma zviri nani mhedzisiro ye distal tibia fracture pane proximal tibia fracture mushure mekugadzirisa fibula.

Maitiro ekuvhiya

Preoperative kugadzirira kwemidziyo yakakosha

Orthopedic bed (traction bed) kana standard fluoroscopic surgical bed; retractor; image intensifier.

Kururamisa kusarudzwa kwe intramedullary nail kureba kwe preoperative endoprostheses

Radiograph

contralateral nhengo kureba kuyerwa

Intramedullary chipikiri dhayamita

x-ray isthmus width

Intramedullary chipikiri kureba kuyerwa

1.Translucent mutongi kutsunga pasi peC-arm machine

Iyo distal uye proximal migumo yebhonzo yakanga iri pakati pe ray; mutongi wacho aienderana nediaphysis.

2.Kuyera kuyerwa maererano nemuviri pamusoro pezviratidzo

Femur: muromo wetrochanter yakakura → lateral ibvi nzvimbo kana danda repamusoro repatella; tibia: medial-lateral knee space → anterior aspect of ankle joint mu dorsiflexion yetsoka.

Intramedullary Nail Insertion Technique - Entry Point Approach

Longitudinal axis ye medullary cavity mumutsara wakatwasuka

Kwete padhuze pekupinda

Kureba kwakakodzera: dilated - kureba; isina kuvharwa - pfupi

(Simbiso isina kunanga yenzvimbo yekupinda; hapana dilation ye pulp, hapana nyoro chengetedzo inodiwa)

Parallel femoral intramedullary nail entry point

Kugadzirira kwenzvimbo yekupinda yeparallel femoral intramedullary nail

Hip flexion uye kuwedzera

Longitudinal incision proximal kune yakakura trochanter

Kwete kure zvakanyanya kumashure

Kuiswa kwepini yemutungamiri

Kuiswa kwenhovo yezvinyoro zvinyoro

Retrograde femoral intramedullary nail entry point

30 ° kuchinjika kwebvi

Yakareba axis yepini yekutungamira munzira imwechete semedullary cavity ye distal femoral stem

Kuiswa kwepini yeKirschner mukati me distal femur kuburikidza ne patellar ligament kuburikidza nekudzivirira sleeve: orthogonal - pakati pe intercondylar fossa ye femur; lateral - mutsara weBlumensaat

Kutanga kwePCL pasina kukuvara

Parallel tibial intramedullary chipikiri yekupinda nzvimbo

Pakati pepakati pemedullary cavity

Anterior margin yetibial plateau

Kukwirira sezvinobvira pasina kukuvadza bani

Maximum ibvi flexion

Incision tibial tuberosity-inferior pole yepatella pamwe chete ne medullary cavity

Vhura iyo medullary cavity: tungamira pini pa 15 ° kune sagittal ndege ye longitudinal axis yetibial stem.

Nzvimbo yemufananidzo intensifier

Marrowing techniques

Kudzikiswa kwemagetsi

mafractures matsva

Manual kuderedza

kutsemuka kwekare nepseudoarthrosis, sclerosis mu medullary cavity

Hapana tourniquet pasi pe inflation

kutenderera kweropa ndicho chinotonhodza chakanakisa

Repositioning maitiro

Parallel femoral intramedullary nailing

Zvikonzero zvekuomerwa mukudzorera kuputsika kwechikadzi

Kuputira kwenyama yakapfava hakubvumiri kupinda kwakananga kune bhonzo

Tsono yekupinda poindi haigone kuoneswa zvakananga

Hip joint adduction → iliac fascia tension → kupfupisa kutyoka

Tibial fracture kuderedza

Manipulation

Kunyanya subcutaneous uye nyore palpate

Kutyoka kwakagadzikana - pakati kana distal A uye B mhando kuputsika

Oblique fractures - overkill

Intramedullary nailing → kutamisa maturusi

Ancillary kuderedza matanho

Point kuderedza forceps

tibia; kushandisa percutaneous kana maronda

Zvikwereti zvakakura (braces)

kunonoka kuderedza; kupfupisa mitezo

Temporary Schanz screws

① Femur, tibia

② Sepedyo nemutsara wekuputsika sezvinobvira

③ Proximal fracture single cortical kushandiswa

④Shandisa chuck yepasirese ine T-mubato wekufambisa zviri nyore

Poller chipikiri

① Metaphyseal kuputsika (kugadzirisa mutsara wesimba, kudzikamisa kudzoreredza, kudzoreredza kushanda)

② oblique kuputsika kwe distal tibia kana femur (kuveura kushushikana → kumanikidza)

③ Zvipikiri zve intramedullary zvisina kumira zvakanaka zvinopinda mugero re medullary panguva yekuvhiyiwa kwechipiri

④ Nzvimbo isina kunaka yekupinda, kurongeka kwakashata kwepakati (screw yakaiswa perpendicular kune inogona kutamiswa kweiyo endoplant)

Yakawedzera yakafara tourniquet

① tibia

② inowedzerwa nekudhonza kana retractor

③ Shandisa nekuchenjerera mukukuvara kwakanyanya kwetishu

④ Ichengetedze ipfupi

⑤ Kurambidza kuwedzera kwe medullary munzvimbo yakakwira

Nail locking sequence: distal ipapo proximal

Zvakanakira

kusununguka kwekugogodza, kudzvinyirirwa kwekuputsika kwekuputika; kubviswa kwekuparadzana; kuderedza mabasa.

Kuderedza maitiro ekunonoka & kuvhiyiwa kusiri kwechipiri

Matambudziko anogona kusangana nekunonoka kuvhiyiwa

Axial deformity (kupfupisa, angulation uye kana kutamiswa)

Kukura kwegranulation tissue

Mabhonzo ekutanga

Sclerosis yekuputsika inoputika nekuvharwa kwemedullary cavity

Osteoporosis

Matambudziko anogona kuitika

Kutsauka kwekuwedzera uye intramedullary chipikiri → intramedullary chipikiri kupinda kwecortex

Angular deformity → retractor

Kubviswa kwemagumo akachekwa → Chipikiri chePoller, kugadzirisa ndiro

Nzira dzekudzivirira mitsara yesimba isina kujairika

Proximal - chaiyo yekupinda poindi

Distal - intramedullary mbambo iri pakati pe medullary cavity

Matambudziko eIntramedullary Nailing

★Infection

★kukuvara kwetsinga

★Kuporeswa kwezvakatyoka

★Medical Fractures

Kutenderera kwekunze, torsion, valgus, kutenderera kwemukati, angulation

★Adjacent joint pain

★Fat embolism

★Heterotopic ossification

★Pulmonary embolism

★Kutyoka zvakare

★Thrombosis

★Kuoma kwejoint

★Kusabatanidzwa kwekutyoka, bhonzo nonunion

★Internal kugadzirisa kukundikana

★Kupfupisa mitezo

★Zvimwe

Matambudziko--Kutapukirwa

1.Pakutanga, kuputsika kwakazaruka kwainzi contraindication kune intramedullary nailing.

2.Kuitika kwehutachiona hwepashure mukuputsika kwakavhurika kunoenderana nemamiriro ekukuvadzwa kwematishu akapfava uye kusvibiswa.

Chiitiko chetachiona mushure mekuputsika kwakavhurika kunoenderana nemamiriro ekukuvadzwa kwenyama yakapfava uye kusvibiswa pamwe chete nenzira iyo iyo nyoro inogadziriswa.

3.Thinner intramedullary misumari inowedzera mukana wehutachiona; isina-yakawedzera kukiya intramedullary zvipikiri kugadzirisa kune hurombo, uye mapfupa emapfupa ane

Iyo isina kuwedzeredzwa yekuvhara intramedullary nail fixation haina kusimba, ine microscopic kufamba kweyakatyoka magumo ebhonzo pamwe neakasara mhango, iri nyore pakukura kwebhakitiriya.

4. Kushandiswa kwekuwedzera uye kushoma kwakawedzerwa kugadziriswa kwe medullary hakusi kungovandudza kugadzikana kwekuputsika, asiwo kunodzivisa kusikwa kwenzvimbo yakafa.

Fat Embolism Syndrome

1.Kuitika kweFES yehurefu tubular bone fractures ndeye 0.5% kusvika 2%.

2. Kuwedzera kwemedulla uye kusawedzera kwemedulla hakuna chinhu chakakosha pamhepo yemapapu.

3.Paunenge uchiwedzera medulla, nzira yacho inofanira kunge ichikanya zvinyoronyoro, kudzivisa simba rakawandisa uye kushanda kwakashata.

4.kuongororwa kwemazuva ano kweFES kuchiri kutora nzira yakarongwa naGurd mu1974, uye kurapwa mushure mekuongororwa kuchanonoka nguva yakanakisisa yekurapa uye inogona kuva nemigumisiro yakakomba.

Kunonoka kuporeswa kwekutyoka uye bhonzo nonunion

Zvinhu zvakasiyana-siyana zvinokanganisa kuporeswa kwekutyoka mushure mekugadzirisa mbambo ye intramedullary, uye zvikonzero zvinogona kuongororwa sezvinotevera.

1.soft tissue yakaiswa mumagumo ekuputsika

2. Kupatsanurwa kwekuputsika kunopera

3. Kukwegura kwemurwere

4. Kuvhurika kutyoka, kukuvara kwakakomba kwenyama yakapfava, yakakomba yenzvimbo hemodialysis kana hutachiona.

5. Yakashata intramedullary nail fixation

6. Yakasanganiswa chirwere cheshuga mellitus kana zvimwe zvirwere zvinodya.

Kuputsika Kwezvokurapa

Kutyoka kunoitwa nemishonga kunonyanya kutsemuka kwechipiri kunokonzerwa nekuita zvisina kunaka panguva ye intramedullary nail fixation.

Intraoperative kutarisisa kunofanirwa kubhadharwa kune

1. Kusarudzwa kusina kururama kwembambo yembambo yembambo kunogona kutungamirira kukuputsika kwepamusoro.

2. Usasundira nesimba mukuwedzera kwe medulla.

3. Mukova wekuwedzera pulp unofanirwa kunge uri munzira imwechete sekutungamira kwekupinza kwembambo.

4. Usashandise simba paunenge uchiisa intramedullary mbambo mu distal end.

Marwadzo mumajoini akavakidzana

1. Kuiswa kwembambo ye intramedullary kunosanganisira zvinyoro zvinyoro uye kunyange kapule yejoint iri padyo neinokwana 1 joint.

2. Iyo tibial plateau yakabatanidzwa kune anterior edge ye medial meniscus ne transverse knee ligament uye inoumba nzvimbo yakachengeteka pamusoro petibial tuberosity kusvika panguva ino. Kana iyo yekurovera iri padhuze nepamusoro kana dhayamita ye intramedullary mbambo yakakura kwazvo, inogona kukonzera kukanganisa kune intra-articular zvimiro, zvichikonzera kurwadziwa kwepashure kwemabvi.

3. Proximal protrusion ye intramedullary nail uye heterotopic ossification ndiyo inonyanya kukonzera kurwadziwa kwehudyu mushure mekuvhiyiwa kwechikadzi intramedullary nail.

4. Proximal protrusion of intramedullary nails, proximal locking mbambo irritation uye rotator cuff kupindira ndizvo zvinonyanya kukonzera kurwadziwa kwefudzi mushure mehumeral intramedullary nailing.