Tibial fractures, suprapatellar intramedullary nail technique

Intramedullary nailing technique yetibial fractures: kuburikidza ne suprapatellar, transarticular approach nemabvi anotenderera pa 20-30 ° uye imwe yekudzivirira chubhu kuchengetedza intra-articular zvivako.

01.Tibial Intramedullary Nailing: kuwana uye kurongeka, anterior ibvi kurwadziwa

Kupinda kwekuvhiya kwe intramedullary nailing ye tibial fractures kwakakosha kuti uise intramedullary mbambo kuburikidza neyakakodzera nzvimbo yekupinda, kuderedza kukuvadzwa kweiyo intra-articular mabvi zvimiro, uye kuwana yakakwana yekutyoka repositioning uye yakakodzera mbambo yekupinda.

Nzira dzekare dzetibial stem fractures ndiyo yepakati infrapatellar kana parapatellar nzira. Kunyange zvazvo nzira idzi dzichiratidzwa kwepakati-chikamu fractures, postoperative valgus, anterior, kana syndesmotic deformities inowanzoitika mune mamwe mafractures akawanda.

Chikonzero chikuru chekusagadzikana mu proximal tibial fractures ndiko kuremara kunokonzerwa nekukwevera kwetendon ye quadriceps panguva yekuputika kwemabvi uye kupesana kwemagetsi pakati pechipikiri chembambo uye posterior tibial cortex panguva yekuisa. Iyo patella inodzivirirawo axial kupinda kwembambo mu sagittal ndege (Fig. 1a, b). Nokudaro, imwe nzira yakajairika yekupinda panzvimbo yacho ndeyepakati peparapatellar incision, iyo inoguma nekupinza zvishoma kwepakati-kune-lateral chipikiri (Figs. 1c uye 2). Sezvo mbambo inopinda mukati me intramedullary canal distal kusvika pakuputsika, chikamu chepamusoro chinoputika mu exostosis (Fig. 2). Pakupedzisira, kushushikana kwekuzorora kweanterior chamber muscles kunobatsira zvishoma kune ectropion (Fig. 3).

Mufananidzo 1 a, b Uchishandisa nzira yakajairika ye infrapatellar, patella inodzivirira kupinda kweaxial yembambo, zvichiita kuti kukanganiswa kwakafanana kweanterior apical sagittal alignment uye ectropion coronal alignment.c Intramedullary nail alignment yakaitwa uchishandisa nzira yeparapatellar.

Mufananidzo 2 Kusvika panopindwa nepakati nepakati parapatellar incision inotungamira kune yepakati zvishoma kune lateral chipikiri kuiswa. Sezvo mbambo ichipinda mumedullary canal distal kusvika pakatyoka (a), chikamu chepakati chinorerekera kuita flare (b)

Fig. 3 Kuzorora kwekunetseka kwechikamu chemukati chemuscle (a) chinobudisa maitiro asina kujeka ectopic (b)

Kuroverera tibia mune imwe nzvimbo yakawedzerwa kunobatsira kudzivisa matambudziko anokonzerwa nehutachiona hwemabvi akanyanya intraoperative.Iyo nzira yakatsanangurwa naGelbke, Jakma et al. muna 2010 uye yakawana mukurumbira mumakore achangopfuura nekuti kuroverera tibia munzvimbo inenge yakatwasuka kunorerutsa kutsemuka nekutyoka. Fluoroscopy yave nehunyanzvi nyore kuita. Nguva yefluoroscopy yesuprapatellar nailing yakanzi ipfupi zvakanyanya pane infrapatellar nailing. Mukuwedzera, kona yekuisa mbambo (mu ndege yesagittal) inonyanya kufanana neyo longitudinal axis yetibia nenzira iyi pane infrapatellar nailing; izvi zvinodzivirira kukakavara kwemagetsi pakati pechipikiri chepipi uye posterior cortex, nokudaro zvichifambisa kuderedzwa kwekutyoka.

Postoperative anterior ibvi kurwadziwa idambudziko rakakodzera. Marwadzo emabvi anterior akataurwa mu50-70% yevarwere vane fractures, vane 30% chete yevarwere vanonzwa kurwadziwa shure kwekubviswa kwekupedzisira. Kuwanikwa-kwakabatana nemavanga ekuumbwa kwe patellar tendon uye Hoffa's mafuta pad yakafungidzirwa kuve inogona kukonzera kurwadziwa kwepashure kwemabvi. Mukuwedzera, nzira ye suprapatellar inodzivisa tsika yechinyakare yekucheka bazi rebazi repatellar re saphenous nerve, iyo inodzivirira kuvharwa kwemabvi anterior uye kusununguka kwekunzwa (Mufananidzo 4). Kupfuudza mbambo kuburikidza ne quadriceps tendon, nokudaro zvichisiya patellar tendon yakasimba, inoratidzika kuderedza zvakanyanya kuwanda kwemarwadzo emabvi epashure.

Fig. 4 Hukama pakati pe saphenous nerve uye zvakasiyana-siyana kusvika kune tibialis obliqua nail.

Nekuda kwemhedzisiro yakanaka yekuputsika kweproximal, zviratidzo zvekiriniki maitiro zvakatambanudzirwa kune zvese zvakaputsika.

Zvinetso zvinogona kuitika ne intramedullary nailing mune suprapatellar nzira:

- Inogona kusiya marara ekudzokorora mumabvi akabatanidzwa. Nekudaro, ruzivo rwekiriniki neretrograde femoral nailing haina kuratidza chero pfupi- kana kwenguva refu yakashata mhedzisiro.

- Kuiswa kunobviswa sei mushure mekunge kuputsika kwapora? Kunyangwe zvichigoneka nehunyanzvi kubvisa mbambo ye intramedullary kuburikidza ne suprapatellar nzira, nzira iyi irikuda uye vazhinji vanovhiya vanosarudza kubvisa intramedullary chipikiri kuburikidza ne infrapatellar nzira.

02.Ini suprapatellar intramedullary nail inofanira kushandiswa riinhi?

Zvakanakira

-Semi-yakawedzerwa ibvi chinzvimbo chinogonesa kutsemuka uye kudzikiswa nekuzorora mhasuru masimba uye kuchengetwa panguva yekuiswa kwembambo.

-Kuderera kwengozi yemashure ekuvhiyiwa malalignment yeproximal, segmental, uye distal fractures zvichienzaniswa nemaitiro echinyakare.

- Nailing iri nyore nyore kuita

- Kuroverera zvipikiri kunogoneka se 'nzira imwe chete yekuvhiya'.

- Yakaderedzwa fluoroscopy nguva

- Hapana kukuvadzwa kune patellar tendon uye zvishoma zviitiko zvepashure-nailing anterior mabvi kurwadziwa

-Iri nyore kuita mune akawanda-timu maitiro, senge polytrauma.

Zvakaipa

-Njodzi yekukuvadzwa kwemabvi cartilage uye zvimwe intra-articular zvimiro

- Kuwedzera kwengozi yehutachiona hwemabvi

- Kubviswa kwekuisirwa kungada imwe nzira

Zviratidzo

-Kuwedzera-kutyoka kweiyo proximal tibia (Type AO 41A)

-Kutsemuka kwakapfava kwetibial diaphysis (rudzi AO 42A-C)

-Segmental tibial diaphysis fracture (rudzi AO 42C)

- Yakawedzera-articular uye yakapusa intra-articular distal yekuwedzera mafractures eiyo distal tibia (mhando AO 43A uye C1)

- Ibvi rinoyangarara

Contraindications

- Gustilo giredhi 3C yakavhurika kuputsika kwetibia nekuda kwekuwedzera kwengozi yehutachiona hwemajoini, kunyangwe njodzi yekuwedzera yehutachiona hwemajoini haina kutaurwa mukuvhurika fractures.

- Yakanyanya nyoro matishu kubvaruka, kusvibiswa kana kutapukira munharaunda ye suprapatellar

- Ipsilateral ibvi prosthesis (relative contraindication)

- Kusanganiswa kwemabvi

- Knee hyperextension>20 °

- Ipsilateral tibial plateau fracture inobatanidza chipikiri yekupinda poindi ihama contraindication

- Maimplants anotadzisa mbambo yekupinda

- Ipsilateral patella fracture (hukama contraindication)

03. Nzira dzekuvhiya

① Chinzvimbo chemuviri uye maonero

Fig. 5 Murwere anorara akafuratira patafura ine radiolucent inobvumira kupatsanurwa-gumbo nzvimbo. Gumbo rakatyoka rinosara rakarembera zvakasununguka uye mupumburu unoiswa pasi pemabvi akabatanidzwa (a) kuti uwane 10-30 ° yemabvi 

(b). I-C-ruoko inoiswa kune rumwe rutivi. Gumbo risina kukanganisa rakaderedzwa 10-30 ° kubva kune yakadzika kuti rive nechokwadi chekufungidzira kwakakodzera munzvimbo ye lateral.

②Tsvaga panopindwa tsono chaipo

Mufananidzo 6 Iyi nzira inoratidzwa ne shaft ye patella, tibial tuberosity, uye anterior tibial cortex. A 2cm longitudinal skin incision inoitwa 1-1.5 cm proximal kune yepamusoro base ye patella. Iyo quadriceps tendon inoratidzwa uye midline longitudinal incision inoitwa munzira yetendon fibers. Iyo suprapatellar recess inovhurwa uye zvigunwe zvechiremba zvinopinda mumabvi akabatanidzwa kubva pasi pepatella kuti aongorore nyore kuwana. Kuwedzerwa zvishoma kwegumbo kunogona kuita kuti uwane kupfugama. Kuiswa kweLangenbeck retractor yekukwira kudiki kwepatella kunogonawo kuwedzera mukana. Kana nzvimbo yejoini yakanyanya kutetepa uye chiridzwa chakaoma, bhendi rekutsigira remukati kana repashure rinogona kuisirwa pedyo naro kuitira kuti semi-dislocate patella kune rimwe divi.

③Kudzivirirwa kwecartilage

Mufananidzo 7 Kudzivirirwa kwepatellofemoral cartilage kubva mukuvhiyiwa-kukuvadza kune chimwe chezvinangwa zvikuru zvekuvhiya. Nokudaro, maoko ekudzivirira anofanira kushandiswa panguva yezviridzwa uye kuiswa kwembambo.a Zvishandiso zvekupinda kwe transarticular zvinosanganisira zvibatiso zvekupinza, kunze (zvinyoro) uye zvemukati (simbi) zvidziviriro zvekudzivirira, trocar pins, uye porous wire guides.b Mabatiro ekuisa anounganidzwa nesleeve yekudzivirira uye yekunze (nyoro) uye yemukati (simbi) inodzivirira pini yepini, tambo yepini yekudzivirira uye tambo yepini. Tsono yetrocar yakaunganidzwa neruoko rwekudzivirira uye mubato wekupinza.b Mubato wekukwirisa une maburi ekufefetera. Iyo knob iri pamusoro pemubato wekupinza inodzivirira kusapinda netsaona kwegadheni remubato

④ Isa iyo guidewire uye gadzirisa chinzvimbo

Mufananidzo 8a Mubatanidzwa wekubata unoiswa pasi pepatella kuburikidza nejoka repatellofemoral kuenda kunzvimbo yaidiwa yekupinda pane tibia (Mufananidzo 9). Muzviitiko zvakawanda, patella inofambisa zvishoma pakati kana nechemberi panguva yekuisa chiridzwa. Iyo groove mumubatanidzwa wepatellofemoral kazhinji inotungamira tsono yetrocar kune iyo chaiyo chinzvimbo.

Fig. 8b Nzvimbo yakasimbiswa mundege dzose dzichishandisa fluoroscopy uye yakagadziriswa pazvinenge zvakakodzera. The trocar tsono inozotsiviwa ne porous guidewire, gwara rinopfuura nepakati pegomba reguidewire uye iro muromo unopinzwa muproximal tibial metaphysis kuti ive nechokwadi chenzvimbo chaiyo.

Mufananidzo 8c Kana iyo guidewire iri mu suboptimal position, yechipiri guidewire inogona kushandiswa kuita zvishoma zvigadziriso munzvimbo iri nani kuburikidza ne porous guidewire, kusvika kuhupamhi hwe 4.3 mm Seimwe nzira, zvingava nyore kutanga ne-guidewire uye kuiisa isina rubatsiro panzvimbo yakakwana yekupinda. Chiridzwa chine muperekedzi chinobva chatsvedzerwa pamusoro pewaya.

⑤ Kuwedzera kwe medulla oblongata

Fig. 9a Kuvhura mhango yemedullary kubva panzvimbo yakakodzera yekupinda inhanho yakakosha mukuvhiya. Mune anteroposterior plane, iyi ndiyo yepakati peiyo lateral tibial spur. Mune lateral ndege, nzvimbo yakarurama yekupinda inowanikwa pakuchinja pakati pearticular surface uye anterior cortex.

Fig. 9b Nzvimbo yakarurama yeguidewire inopindirana ne-tibial axis mu anteroposterior plane uye iri pedyo nekuenzanisa kune anterior cortex sezvinobvira mu lateral projection. Iyo guidewire inowanzo famba ichienda kumashure.

Mufananidzo 9c Muzviitiko apo pini kana chipikiri chisingagoni kuiswa zvakanaka, kuvharira chipikiri kana pini kunobatsira kutungamira chipikiri panzvimbo yakarurama. 

Kuvhara zvipikiri kunoshandiswa munzvimbo yakafara metaphyseal apo iyo guidewire kana mbambo haigone kutariswa zvinoenderana neiyo longitudinal axis yepfupa kana kana kuputsika kusarongeka mune imwe kana maviri ndege inoramba iri panguva yekuiswa kwembambo.

Mufananidzo 10 Panguva ino, zvinokurudzirwa kuti mubato wemubato uchengetedzwe kune femoral condyle uchishandisa 3.2 mm gwara waya. Izvi zvinodzivirira gungano kubva pakubuda kwetibia.

Mufananidzo 11 Iyo 12.0 mm hollow drill bit inoiswa kuburikidza nemukati inodzivirira sleeve uye ichidzika kuburikidza negiidhi waya kusvika kubhonzo. Medullary canal inovhurwa nekuboora kusvika pakadzika 8-10 cm uye bhora-inopera gwara rinopinzwa muproximal tibia.

⑥ Kuputsika kuderedzwa

Mufananidzo 12a Panguva ino, tinogadzirisa zvakare kuputsika.

Mufananidzo 12b Zvichienderana nenzvimbo yekuputsika uye morphology yayo, zvishandiso zvakasiyana-siyana zvekudzikisa zvakadai sepercutaneous clips, retractors, mahwendefa maduku maduku, uye zvivharo zvekuvhara zvinogona kushandiswa kuwana kurongeka kwakakodzera. In proximal tibial fracture kuderedza, dzimwe nguva kunyange nerubatsiro rwekuwedzera kudyara, usati wavhura medullary canal nekuchera. Iyo reming tsvimbo inokwidziridzwa kure uye inopinzwa pakati peiyo distal tibial metaphysis. Mushure mekugadzirisa zvakare, kureba uye dhayamita yembambo zvakatemwa. Kana zvichidikanwa, wedzera iyo tibial canal kusvika kune yaunoda dhayamita nekudzokorora mu 0.5 mm increments. Kuvhura mubato rekudzivirira sleeve kunobvumira kutsvaira uye kusvetwa kwemarara kubva pajoini panguva yekudzoreredza. Kana zvichibvira, zvinokurudzirwa kuti mbambo ine dhayamita shoma ye10 mm ishandiswe. Iyo 5.0 mm Locking Bolt yerudzi urwu rwembambo inoshingirira kutadza kupfuura 4.0 mm Locking Bolt inoshandiswa pazvipikiri zvakatsetseka. Kureba kwezvipikiri zve intramedullary kunowanzogadziriswa nemutongi we fluoroscopic.

⑦ Isa intramedullary chipikiri

Mufananidzo 13a Kupinzwa kwembambo kuburikidza netsvimbo yekudzokorodza pasi pefluoroscopy. Ziva kuti mubato wekuisa we suprapatellar nail wakareba kupfuura iwo we infrapatellar mbambo nekuti chinhambwe kubva paganda kuchekwa kusvika patibial chipikiri chekupinda nacho zvakareba.

Mufananidzo 13b Ndapota cherechedza kuti bend (Herzog curve) pamagumo ekupedzisira kwembambo ye intramedullary haigoni kuiswa kuburikidza nesimbi yemukati inodzivirira sleeve. Naizvozvo, iyo yemukati inodzivirira sleeve inofanira kubviswa kubva pakubatanidzwa kwemubato isati yaiswa mbambo (b; ona chikamu 'Kukanganisa, Ngozi uye Matambudziko'). Tarisa nzvimbo yekupedzisira ye intramedullary nail mune anterior-posterior uye lateral maonero. Bvisa reming rod. Kana chipikiri ichida kutsiviwa, siya simbi inodzokororwa panzvimbo uye isa mbambo itsva mutsvimbo. 5 mm zviratidzo pamubato wekuisa unoratidza hudzamu hwekuiswa kweiyo implant mu proximal tibia (Fig. 14). (Mufananidzo 14)

⑧ Distal uye proximal kukiya

Mufananidzo 14a Proximal uye distal yekuvhara masisitimu zvinoenderana neakananga fracture maitiro. Proximal locking inogona kuitwa neruoko rwakanangwa. Distal locking inoitwa freehand kana kushandisa radiopaque drill guide. Sarudzo, chivharo chekupedzisira chinogona kushandiswa, icho chinodzivirira pfupa kubva pakukura kusvika kumagumo eiyo intramedullary chipikiri uye inofambisa kubviswa kweiyo implant. Kunyanya, zvipikiri zvakapfurikidza zviri nyore kubvisa kana zvivharo zvekupedzisira zvehurefu hwakakodzera zvinoshandiswa. Hurefu hunodiwa hwechivharo chinopimwa nekuisa mucherechedzo pamubato kana nekuisa tambo yegwara neruoko rwakanangisa.

Mufananidzo 14b Iyo muromo weiyo guidewire inoratidza nzvimbo yepedyo ye intramedullary nail. Iyo screw inobatanidza ruoko rwekunangisa kune chipikiri inoda kubviswa kuti uise iyo yekupedzisira cap. Chivharo chekupedzisira chinopfuura nepakati pechirongo chemubato wekuisa. Mubato wekuisa unoramba uripo. Izvi zvinogadzirisa chivharo chekupedzisira nechepamusoro pe intramedullary nail uye inodzivirira kuti irege kurasika mumabvi. Kupinza iyo guidewire kuburikidza nebarrel end cap mukati mekupedzisira kwembambo kunobatsirawo kutungamira chivharo chekupedzisira kune chinzvimbo chayo chakakodzera kumagumo eiyo intramedullary chipikiri. Pakupera kwekuita, mushonga wesaline usina kuchena unofanirwa kugezwa kuti usuke chero marara asara.

04. Yambiro

Chengetedzo Yekuvhiya Kuvhiya

- Muzviitiko zvepreexisting osteoarthritis, kurambidzwa patellar kufamba kunogona kudzivirira kubatana. Incision yechikamu chepamusoro chebhendi rekutsigira remukati kana remberi kubva kudivi remukati rinoita kuti kuiswa kwepini yetrocar.

- An ipsilateral ibvi prosthesis haisi yakasimba contraindication kune suprapatellar pinning. Ziva, zvisinei, kuti zvingave zvisingakwanisi kuwana iyo yakajairwa kutanga kweiyo proximal tibial nailing maitiro.

-Mukutsemuka nearticular extension, mamwe ma screws anogona kuiswa kuti asafambe ne articular fracture component. Zvinokurudzirwa kuti zvipikiri izvi zviiswe pamberi pekupinzwa kwembambo kudzivirira kusimuka kwechipiri kweiyo articular fracture.

Proximal Tibia Fracture Kufunga

Proximal tibial fractures ndiyo yakanyanya kuoma tibial fractures kune mbambo uye inoda chaiyo yekupinda mapoinzi (sezvatsanangurwa pamusoro apa). Aya mafractures anofanirwa kuderedzwa asati arovererwa kurwisa chero masimba anokanganisa uye kuwedzera kubudirira. Mune zvimwe zviitiko, kunyatsoisa nhengo yakakanganiswa munzvimbo yakawedzerwa uye kuwana nzvimbo chaiyo yekupinda uye kuisa mbambo ne medullary canal mu coronal uye sagittal axes ichaita kuti kurongeka kwakakodzera kwetibia mushure mekurovera.

Nekudaro, muzviitiko zvakawanda, kumwe kudzikisa maneuver kunodiwa kuti uwane uye uchengetedze inogutsa reposition yekutyoka uku. Kana mutsara wekutyoka uri nyore uye wakatenderedzwa, akareruka akanongedza kuseta zvisungo kana coaptation clamps, akaiswa percutaneously, anogona kushandiswa kuwana nekuchengetedza reset panguva yekurovera. Kana chisungiso chisina kukwana kana kuti ndege yekutyoka ikasakweretesa kusungirira, mukume kana kuvharira screws zvinogona kubatsira kudzivirira kusimuka uye kusamira zvakanaka (Mufananidzo 15). Aya screws anoiswa kumashure kune inodiwa mbambo chinzvimbo pane lateral maonero uye lateral kune inodiwa mbambo chinzvimbo pane anterior-posterior maonero. Kuiswa kwakakodzera kweaya screws kuti agadzirise zvakanaka anogona kunetsa.

Fig. 15 Kukiya masiruu akaiswa kunze kwenzira yembambo inodiwa pamberi uye kumashure maonero (a) uye kuseri kwekwaidiwa mbambo nzira mudivi rekuona (b) kupikisa mauto e deformation.

Imwe nzira yakanyatsoshanda ndeyekugadzirisa kwechinguva kwekuputsika munzvimbo yeanatomic (Fig. 16). Kazhinji chimedu chimedu tubular ndiro ine maviri kana matatu single cortical locking screws inobata kutsemuka kwakaderedzwa panguva yekugadzira canal midzi uye kuiswa kwembambo. Iyo ndiro ichadzora zvese zvinotamiswa. Iyo ndiro inofanira kusiiwa munzvimbo chero bedzi pasina gaka rakagadziriswa kudzivirira kurasikirwa kwekuderedza kunowanzoitika mushure mekubviswa kweplate. Iri ndiro rine imwe cortical screw haina kuomarara uye haizokanganisa kugadzikana kwembambo. Iyo reset plate tekinoroji inogona kushandiswa kune ese akavhurika uye akavharika mafracture.

Mufananidzo 16 Indiro diki yekukiya ine imwe cortical screw inogona kuwanikwa uye kuchengetedzwa mune anatomic reposition. Kazhinji, ndiro inofanira kusiiwa panzvimbo mushure mekurovererwa. A Initial valgus deformity yeproximal tibial fracture. b Indiro diki yekutyoka ine imwe cortical screw inoiswa pakati kuti iwane uye ichengetedze kutsemuka repositioning panguva yekurovererwa. c Iyo ndiro haibviswe mushure mekurovererwa nekuti inopa kugadzikana kwekuwedzera

Misalignment, Ngozi uye Matambudziko

- Intraoperative displacement yeProtective Sleeve inogona kukonzera kukanganisa kune cartilage uye intra-articular knee structures (Mufananidzo 17). Sleeve yekudzivirira inofanira kuiswa zvakare zvizere.

-Kurereka kushoma kweChidziviriro Sleeve kunogona kuwedzera reamer kubviswa kwemusoro. Fluoroscopy inobatsira kuona dambudziko. Kugadziriswazve kwechivharo chekudzivirira kuchagadzirisa dambudziko (Fig. 18)

- Nail Lock-Up: Iyo implant inogona kunamira musimbi sleeve pane proximal bend (Herzog curve). Pakupinzwa chipikiri kwekupedzisira, chubhu yesimbi inoda kubviswa, kuchisiya chete sleeve yepurasitiki yakapfava yekunze. Kana mbambo yanamira, inoda kubviswa zvachose zvakare uye inoiswa zvakare mushure mekubvisa simbi cannula kuburikidza nepurasitiki cannula chete.

Mufananidzo 17 Kubvisa sleeve yekudzivirira pasina kutarisa kwefluoroscopic kunogona kukonzera kukuvara kwebvi

Mufananidzo 18 a Kurereka kana kurereka netsaona kwekasi yekudzivirira kunogona kukanganisa kubviswa kwe remer, sezvo musoro we reamer ungajam. b Kuongororwa kwefluoroscopic nekugadziriswa kwekugadzirisa kunobvumira kubviswa kwemusoro we reamer. c Musoro we remer unogona kubviswa kana remer musoro usipo. d Musoro we remer unogona kubviswa kana remer musoro usipo.

References

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