Tibial fractures, suprapatellar intramedullary zvipikiri zvechisimba

Intramedullary Nailing Technique yeTibial Fractures: Kupfuura Suprapetallar, Superticuly maitiro nebvi rakachinjika na 20-30 ° uye chaiyo yekudzivirira yekuchengetedza iyo inochengetedza zvinyorwa zvemukati.

01.Tibial intramedullary mbiri: kupinda uye kuwirirana, anterior leeby kurwadziwa

Kuvhiya kwekuvhiya kweIntramedully

Iyo nzira dzekare dze tibial stem fractures ndiyo yepakati infrapallar kana parapatellar inosvika. Kunyangwe aya mafambiro achiratidzwa pakati pezvikamu zvikamu, postopengerative valgus, anterior, kana gadziriro syndidesmotic inowanzoitika mune zvimwe proximal fractures.

Chikonzero chikuru cheMalagmment muProximal tibiel fractures inokonzerwa nekukwevera kweiyo quadriceps nebvi rekupindirana pakati pechidimbu chechipfuva Cortic Iyo Patella zvakare inodzivirira kupinda kweiyo yetsikisi yechipikiri muiyo sagittal ndege (Fig. 1a, b). Naizvozvo, imwe nzira yakajairika yekupinda iyo poindi iri kuburikidza nepakati pepasicarlar incision, iyo inoguma mune zvishoma zvemukati-kusvika-kune-inozotevera zvipikiri (maonde. 1c uye 2). Sezvo chipikiri chinopinda mumatare emukati mernal Pakupedzisira, kushushikana kwekuzorora kweiyo anterior chammy tsandanyama kunopa zvishoma kune iyo ectropion (Fig. 3).

Mufananidzo 1 A, B Uchishandisa kujairika kwekunyepedzera, patella inodzivirira kupinda kwechipikiri, kuremerwa kweanorema kweAnagitment.

Mufananidzo 2 uchisvika padanho rekupinda kuburikidza neyekupinda mindapatellar incision inotungamira kune zvishoma m mezvi kuti uve wepfumo pasi. Sezvo chipikiri chinopinda muye mipikisane canal disal distal kune kupwanyika (a), iyo proximal chikamu chakasungirirwa mu flare (b)

Fig. 3 kuzorora kwekunetsana kweiyo anterior muscle compartment (a) inoburitsa subtle yectopic gadziriro (b)

Kuvhiringidza Tibia kune imwe nzvimbo yakawedzerwa inobatsira kudzivisa matambudziko anoenderana neyakanyanya intraoperative ibvu.hunyanzvi akatsanangurwa naGelbke, Jakma et al. Muna 2010 uye akawana mukurumbira mumakore achangopfuura nekuti kubhururuka kweTibia muchinhu chakatsiga chenzvimbo chakaringana kurerutsa manyoka uye kudzoreredza. Fluoroscopy yaita hunyanzvi nyore kuita. Iyo fluoroscopy nguva ye suprapatellar mbichana yave ichinzi yakapfupika kupfuura yeinfrapatellar upment. Uye zvakare, chipikiri chinoisa angle angle (mune iyo SAGITTAL ndege) inoenderana neiyo refuitudinal axis yeTibia neiyi nzira kupfuura neinfepellar uping; Izvi zvinodzivirira muchinjiro wekurovera pakati pechipikiri chechipikiri chechipatara uye pachinzvimbo chekamuri, nekukasira kuderedza kuderedzwa.

Postoperative anterior knee kurwadziwa idambudziko rakakodzera. Anterior knee kurwadziwa kwakataurwa mu50-70% yevarwere vane mapundu, aine chete makumi matatu muzana evarwere chete vachirwadziwa pakubviswa kwekuparadzwa kweshungu. Kuwanikwa-kwakanangana nengarava yekuumbwa kwePatellar Tendon uye Hoffe's Fat Pad yakafungidzirwa kuti ive inogona kuve inokwanisa kubva pakurwadziwa kwebvi rekupaza. Uye zvakare, iyo suprapetallar mashandiro anodzivisa kusanzwisiswa kwebazi rebazi rePatellar yeruva reSaphenous, iro rinodzivirira munhu anterior knofness uye akadururwa sensation (Mufananidzo 4). Kupfuura namaira kuburikidza ne quadriceps Tendon, nokudaro uchisiya patellar tendon isina simba, inoratidzika kunge inoderedza zvakanyanya mwero wekurwadziwa kwebvi rekupaza.

Fig. 4 Hukama pakati peSaphenous nerve uye dzakasiyana kuwanikwa kune tibialis obliquia mbambo

Nekuda kwemhedzisiro yakanaka kwazvo yekufungidzira, zviratidzo mumakiriniki maitiro akawedzerwa kune ese mapundu.

Matambudziko angangogona nemisangano yemukati mune iyo nzira yekufungidzira nzira:

-Kugona kusiya kudzora marara mubvi. Nekudaro, chirwere chekiriniki chine retrograde femory chipfukuto chisati charatidza chero pfupi- kana kwenguva yakareba mhedzisiro.

- Iko kusurindirwa kwakabviswa sei mushure mekupwanya kwapera? Kunyangwe izvi zvine hunyanzvi zvichikwanisika kubvisa chipikiri chinomarara kuburikidza ne suprapatellar maitiro, maitiro arikuda uye vanachiremba vazhinji vanofarira kubvisa chipikiri chinomarara kuburikidza neinfepellar.

02.wiyo runofanirwa ne suprapatellar intramedullary chipikiri kushandiswa?

Zvakanakira

- Semi-yakawedzera ibvi nzvimbo yekufambisa inoshambadzira manipulation uye kuderedza nemauto ekuzorodza kwemasuru uye kuchengetwa panguva yekamati yekuisa.

- Yakadzika njodzi yekudzora chilementment yeProximal, Segmental, uye distal fractures zvichienzaniswa nehunyanzvi hwechinyakare

- Mbiri ndeyechokwadi zvine hunyanzvi nyore kuita

-Kuperera kunoonekwa se 'Chiero cheRuranga Imwe Chekuvhiya '.

- yakaderedzwa fluoroscopy nguva

- Hapana kukuvadzwa kune patellar tendon uye kushoma zviitiko zvekutumira-kupindira anterior abvi kurwadziwa

- zviri nyore kuita mune yakawanda-timu maitiro, sezvakaita ne polytrauma.

Zvinokuvadza

- njodzi yekukuvara kwebvi cartilage uye zvimwe zvimiro zveIntra-articular

- yakawedzera njodzi yebvi utachiona

- Kubviswa kweiyo Implant ingangoda nzira dzakasiyana

Zviratidzo

- Yakawedzera-articular Fractures yeiyo Proximal Tibia (Type AO 41A)

- Zvirinani Commined Fractures yeTibial diaphiysis (Type AO 42a-c)

- Segmental tibial diaphysis fracture (Type AO 42c)

- Yakawedzera-yehunyanzvi uye yakapusa intra-articular distal extension fractures yeTibia (mhando AO 43A naC1)

- Kuyerera ibvi

Kukanganisa

- Gustilo Giredhi 3c Akavhurika Zvipfeko zveTibia nekuda kwekuwedzera njodzi yehutachiona hwehukama, kunyangwe hazvo njodzi yakawedzera yehutachiona hwehukama haina kutaurwa mumatanho akazaruka

- yakanyanya nyoro nyoro misodzi kubvarura, kusvibiswa kana hutachiona mu suprapatellar mudunhu

- Ipsilateral Knee prostisesis (Consele Kubata)

- Knee Fusion

- Knee hyperextension> 20 °

- Ipsilateral tibial Plateau kupwanya inosanganisira chipikiri chekupinda Point ndeyekushomeka kwehukama

- Implarti inovandudza mbichana nzvimbo yekupinda

- Ipsilateral Patella Fracture (Contraging Controption)

03. Nzira dzekuvhiya

① Nzvimbo yemuviri uye maonero

Fig. 5 Nhema dzePations Supine pane patafura yomutoo redhiyo inobvumira kupatsanurwa-gumbo chinzvimbo. Iyo yakakuvadzwa gumbo rasara rakarembera zvakasununguka uye mupumburu unoiswa pasi pebvi rakabatanidzwa (a) kuzadzisa 10-30 ° yebvi yekubhururuka 

(b). Iyo C-ruoko inoiswa kune rimwe divi rakatarisana. Gumbo risina kuderedzwa rinoderedzwa

②Findira yakakodzera yekupinda yekupinda Point

Mufananidzo 6 Iyi nzira inoonekwa neiyo shaft yePatella, tibial tubority, uye anterior tiibi cortex. A 2 CM Longitudinal Ganda Incision inoitwa 1-1.5 cm proximal kune yepamusoro base yePatella. Iyo quadriceps Tendon inofumurwa uye yepakati Longitudinal incision inogadzirwa munzira yeiyo tendon fibers. Iyo suprapatellar yekuzorora yakavhurwa uye zvigunwe zveurgeon zvinopinda mubvi kubva pazasi pePatella kuti uongorore kusununguka kwekuwana. Kuwedzerwa kudiki kwegumbo kunogona kufambisa kupinda kwejekisi. Kuiswa kweiyo langenbeck restor yekukwirira kudiki kwePatella inogona zvakare kusimudzira kuwana. Kana iyo nzvimbo yakabatanidzwa ichinyanya kutetepa uye yakasimba yakaoma, iyo medial kana yekare rutsigiro bhendi inogona kuiswa proximal kune iyo kuitira kuti ive-dislocate iyo patella kune rimwe divi rimwe.

③Protection ye cartilage

Mufananidzo 7 Dziviriro yePatefeloFERAL Cartilage kubva mukukuvara-kwakanangana neyakawoneka ndechimwe chezvinangwa zvikuru zvehunyanzvi hwekuvhiya. Naizvozvo, nzizi dzinodzivirira dzinofanira kushandiswa panguva yechigadzirwa.Almentions.a (simbi) uye yemukati (nyoro) uye yemukati (simbi) yekudzivirira, pini yekudzivirira, uye pini yemukati, uye pini yemoto, uye pini yemoto. Iyo trocar sindano yakaunganidzwa neyekudzivirira uye kuisa mubato Iyo banga pamusoro peiyo yekuisa inobata inodzivirira kushungurudzika kwesungano yekubatira

④ Isa iyo yekutungamira inotungamira uye gadzirisa chinzvimbo

Mufananidzo 8A iyo musangano webasa rakaiswa pasi pePatella kuburikidza nePatelloFemoral Joint kune iyo yaunoda yekupinda Point paTibia (Mufananidzo 9). Muzviitiko zvakawanda, patella ichafamba zvishoma pakati kana gare gare panguva yekuisa chiridzwa. Iyo Groove mune PatelloFemOral Joint inowanzotungamira maTrocar sindano kune chinzvimbo chakakodzera.

Fig. 8B chinzvimbo chakasimbiswa mune ese ndege uchishandisa fluoroscopy uye yakarongedzwa pazvinenge zvakakodzera. Iyo trocar sindano yatsiviwa neine pousus inotungamira

Mufananidzo 8C Kana iyo yekutungamira iri muchinzvimbo cheSubopt Iyo yekuisa chiridzwa ine iyo inotungamira iyo inotsvedza yakadzika pamusoro pemutungamiriri.

⑤ Kuwedzera kweiyo Medulla Oblongata

Fig. 9A kuvhura medullary cavity kubva pane yakakodzera yekupinda nzvimbo inhanho yakaoma mune yekuvhiya maitiro. Mune iyo anteroposter ndege, iyi ndiyo medial chikamu cheiyo inotevera tibial tibial spur. Mundege yakati wandei, iyo chaiyo yekupinda poindi iri pachinjiro pakati peiyo articular pamusoro uye anterior cortex.

Fi. Iyo yekutungamira inotungamira inowanzoenda kumberi.

Mufananidzo 9c mune zviitiko apo pini kana chipikiri chisingakwanisi kuiswa nenzira kwayo, kuvhara mbambo kana pini inobatsira kutungamira chipikiri munzvimbo chaiyo. 

Blocking zvipikiri zvinoshandiswa mune yakawedzera metaphyseal dunhu kana iyo inotungamira iyo kana chipikiri chisingakwanise kufanana neiyo pfupa repfupa kana kana rakapepetwa mune imwe kana ese maLeges panguva yekuisa neti.

Mufananidzo 10 Panguva iyi, zvinokurudzirwa kuti musangano wekubata unochengetedzwa kuConder Condyle rechikadzi uchishandisa A 3.2 MM Guide Wire. Izvi zvinodzivirira gungano kubva pakubuda mu tibia.

Mufananidzo 11 iyo 12,0 mm Hollow Drill Bit inoiswa kuburikidza neiyo yemukati yekudzivirira sleeve uye pasi kuburikidza neyekutungamira iyo pfupa. Iyo medullary canal yakavhurwa nekukwevera kusvika pakadzika kwe 8-10 cm uye bhora rakapera kutungamira

⑥ Kuderedzwa kuderedza

Mufananidzo 12A panguva ino, isu tidzoreredze kupwanya.

Mufananidzo 12B zvichienderana nenzvimbo yekupwanya uye morphology, midziyo yekudzikisira kwayo senge precutaneous, mahwendefa madiki ekutsvaira, uye anovharira zvigadziko zvinogona kushandiswa kuzadzisa zvakaringana. MuProximal Tibial Fracture kuderedza, dzimwe nguva kunyangwe nerubatsiro rwezvevaridzi zvekuwedzera, usati wavhura medullary canal nekukwevera. Tsvimbo yekudzokorora inokatyamadza kureba uye yakaiswa pakati peiyo distal tibial metaphysis. Mushure mekushandurwa, kureba uye kuyamwisa mbambo kwakatemwa. Kana zvichidikanwa, kuwedzera iyo tibial canal kune iyo yaunoda dhayamita nekugadzirisa mu 0.5 mm kuwedzerwa. Kuvhurika mune inodzivirira sleeve mubato kunobvumira kuputika uye kusvetuka marara kubva pakubatana panguva yekutumira. Kana zvichikwanisika, zvinokurudzirwa kuti mbambo ine dhaisiki diki yegumi mm ishandiswe. Iyo 5.0 mm Locking Bolt yeiyi mhando yechipikiri zvakanyanya kupesana nekutadza kupfuura iyo 4.0 mm mm locking bolt inoshandiswa zvipikiri. Kureba kwechipikiri cheIntramudelly kazhinji kunowanzofungidzirwa nemutongi wemifananidzo.

⑦Insert intramedullary zvipikiri

Fig. 13a nail yekuisa kuburikidza neyekugadzirisa tsvimbo pasi peFluoroscopy. Cherekedza kuti kubata kwekuisa kweiyo suprapatellar mbambo kwenguva yakareba kupfuura iyo yeiyo Infrapatellar mbichana nekuti chinhambwe kubva kuganda incision kune tibial nail nail nail nail yekupinda nzvimbo yekupinda zvakare.

Mufananidzo 13B Ndokumbira utarise kuti Bend Naizvozvo, iyo yemukati yekudzivirira yekudzivirira inofanira kubviswa kubva kugungano rekubata usati waisa chipikiri (b; ona chikamu 'zvikanganiso, njodzi uye zvinonetsa uye zvinonetsa '). Tarisa iyo yekupedzisira chinzvimbo cheiyo intramedullary chipikiri muAnterior-Posterior uye Stareral maonero. Bvisa tsvimbo yekutumira. Kana zvipikiri zvichida kutsiviwa, siya tsvimbo yekutumira munzvimbo uye isa mbambo nyowani mumvuri. 5 mm mm moni pane yekuisa ruoko kuratidza kudzika kwekuisa kwekuisa kwekuisa muiyo proximal tibia (Fig. 14). (Mufananidzo 14)

⑧ distal uye proximal kuvhara

Mufananidzo 14A proximal uye distal Locking Concing Inotsvaga pane chaiyo Fracture maitiro. Proximal kukiya kunogona kuitwa neruoko rwekuvaririra. Distal kukiya kunoitwa wakasununguka kana kuburikidza nekushandiswa kweiyo radiopaque dradi. Sarudzo, kapepa magumo inogona kushandiswa, iyo inotadzisa pfupa kubva mukukura muProximal mugumo wechipikiri cheIntramedullary uye mafambisirwo anozotevera kubviswa kweiyo motolant. Kunyanya, zvipikiri zvakawandisa zviri nyore kubvisa kana magumo emapepa ehurefu hwakakodzera anoshandiswa. Iyo yakazadzwa nehurefu hwekupedzisira cap inoyerwa nekuisa chiratidzo pane iyo mubato kana nekuisa waya yekutungamira kuburikidza neruoko rwechirume.

Mufananidzo 14B iyo tipiti yemutope inoratidza iyo proximal chinzvimbo cheiyo intramealry chipikiri. Iyo screw inobatanidza ruoko rwakatarisana nemukana runoda kubviswa kuti uise magumo cap. Iyo yekupedzisira cap inopfuura nepakati pebhari rekuisa chibvumirano. Iko kuiswa kunoisa chinobata chasara munzvimbo. Izvi zvinogadzirisa mugumo cap uye kumusoro kweiyo intramedullary chipikiri uye inodzivirira kubva pakurasika mubvi. Kuisa iyo Buttiwire kuburikidza nebhari yekupera cap muProximal mugumo wembambo zvakare inobatsira kutungamira cap kune kwayo nzvimbo yakakwana mune iyo proximal kupera kweiyo intramedularary chipimo. Pakupera kwemaitiro, saline saline solution inofanira kusukwa yekugeza chero marara akasara.

04. Kunyevera

Kuchenjera kwekuvhiya mashandiro

- Mune zviitiko zvekunyepedzera osteoarthritis, akarambidzwa patellar motion anogona kudzivirira kupinda. Incision yechikamu cheiyo yeproximal yemidhudhi kana yekare rutsigiro bhendi kubva kune medial divi rinopa kuiswa kweTrocar Pin.

- Iyo ipsirilateral ibvi prostistsis haisi yekukanganisa kwakasimba kuenda ku Suprapatellar Pinning. Ziva, zvisinei, kuti zvingave zvisingaiti kuwana iyo yenguva dzose kutanga nzvimbo yeiyo proximal tibial uproction maitiro.

- Muzvipundu nekuwedzera kwekuwedzera, zvimwe zviyero zvinogona kuiswa kuti usimbe unzenza zvinokatyamadza. Zvinokurudzirwa kuti zviyero izvi zviiswe pamberi pekuisa zvipikiri kuti urege kudzivisa kudzikisira kweshamwari yeiyo yekunyepedzera.

Proximal tibia inovhiringidza kufunga

Proximal tibial fractures ndiyo inonyanya kuoma tibial fractures kuchidimbu uye inoda chaiyo yekupinda mapepa (sekutsanangurwa pamusoro). Izvi zvidimbu zvinofanirwa kuderedzwa zvisati zvatanga kupindira kuti udzivise chero mauto anoremara uye kuwedzera kubudirira. Mune zvimwe zviitiko, kumisa zvine musoro kusimuka kwenzvimbo mune imwe nzvimbo yekupinda uye nekuisa mbambo yekupinda nepakati uye neyekupedzisira mademo uye sagittal axes anozoguma nekuwirirana kwakakodzera kweTibia mushure mekutarisirwa.

Nekudaro, kazhinji, kumwe kuderedza maneja anodikanwa kuti awane uye kuchengetedza kudzikama kunogutsa kweaya mafrainiti. Kana mutsara wetsiva wakareruka uye wakareruka, wakareruka, wakareruka reseting contrmps kana conptation clamps, yakaiswa percolyly, inogona kushandiswa kuwana uye kuchengetedza reset panguva yekuvandudza panguva yekuvandudza. Kana iyo clamp haina kukwana kana iyo yekukasira ndege isingazvikweretesa kuti ishandise, pollen kana kuvhara zviyero kunogona kubatsira kudzivirira kudzikisira uye kushomeka (Mufananidzo 15). Iyi screws yakaiswa posterior kune inodiwa chipikiri chinzvimbo pane iyo inotevera maonero uye yakazotevera kune inodiwa chipikiri chechipikiri chesimba pane iyo Anterior-poster fairs. Kuiswa kwakakodzera kweaya zviyero zvekugadzirisa zvakanaka kunogona kuve kwakaoma.

Fig. Mahwendefa ekuvhara gumi nemashanu akaiswa kunze kweiyo yepamhepo yepamhepo nzira kumberi uye kumashure maonero (a) uye kumashure kweiyo yepikiri yepamhepo nzira mumaonero (b) kurwisa masimba ekuremadza

Imwe nzira inobudirira kwazvo ndeyekugadziriswa kwechinguvana kwekupwanya mune anatomic chinzvimbo (Fig. 16). Kazhinji chidimbu chidiki chiduku tubular chine maviri kana matatu ega cortical kuvhara zviyero zvinobata kupwanyika kwakaderedzwa panguva yekugadzirira midzi uye nepikiri neti. Ndiro ichadzora zvese zvadzinoenda. Iyo ndiro inofanirwa kusiiwa munzvimbo chero bedzi pasina Gap yakatarwa kuti udzivise kurasikirwa kwekudzikiswa kunowanzoitika mushure mekubviswa kwelat. Iyi ndiro ine imwe chete cortreal screw haina kuomarara uye haizokanganisa kugadzikana kwembambo. Iyo reset plate maitiro inogona kushandiswa kune ese akavhurika uye akavharwa zvikanganiso.

Mufananidzo 16 Chikamu chidiki chekuvhara chine screw imwe chete chinogona kuwanikwa uye chengetwa muAnatomic reposition. Muzhinji, ndiro yacho inofanira kusiiwa munzvimbo mushure mekupindira. kushungurudzika kwekutanga kwevalgus kweiyo proximal tibial kupwanya. B diki diki rinokatyamadza neyakafanana cortreal screw yakaiswa mukati mekuwana uye kuchengetedza kupwanywa kudzokorora panguva yekuvhenekera panguva yekuvhiringidza. c ndiro haina kubviswa mushure mekuvhiringidza nekuti inopa kugadzikana kwekuwedzera

Misangano, njodzi uye zvinonetsa

- Intraoperative kudzikiswa kweiyo sleeve yekudzivirira inogona kukonzera kukuvara kune cartilage uye intra-articular ibvi zvivakwa (Mufananidzo 17). Nguo yekudzivirira inofanira kuve yakanyatsogadzirwazve.

-Kushoma kusvetuka kweiyo dombo rekudzivirira kunogona kuwedzera kudzokorora musoro wekubvisa. Fluoroscopy inobatsira kuziva dambudziko. Kugadziridzwa kweiyo iyo yekudzivirira sleeve ichagadzirisa dambudziko (Fig. 18)

- Chipikiri Lock-up: Iyo Implant inogona kunamatira mune simbi sleeve kuProximal Bend (Herzog Curve). Zvekupedzisira zvipikiri zvipikiri, iyo simbi tube inoda kubviswa, ichingosiya chete iyo yekunze yakapfava yepurasitiki sleeve. Kana mbambo yakanamatira, inoda kubviswa zvizere zvakare uye iyo yekuisa yakasungirirwa mushure mekubvisa iyo simbi cannula kuburikidza nepurasitiki cannula chete.

Mufananidzo 17 Kuchengetedza Sleeve Kubvisa pasina Fluoroscopic Kuongorora kunogona kutungamira kukuvara kwebvi

Mufananidzo 18 Une tilting kana tsaona tsaona yekudzivirira kwekudzivirira inogona kukanganisa kudzurwa kwekubvisa, sekutazve musoro wemusoro. b Kuongorora kweFluoroscopic nekuregererwa kwekururamisa kunobvumira kubviswa kwemusoro wezve reamer. c musoro wezve reamer unogona kubviswa kana musoro wezve reamer usiri munzvimbo. D iyo Reamer musoro inogona kubviswa kana musoro webasa racho risiri munzvimbo.

Mareferensi

Hessmann mh, Buhl m, finkemeier c, khotureier a, moshiiff r, blauth m. Suprrapatellar mbiru dzeTibia. Oper Orthop traumatol. 2020 Oct; 32 (5): 440-454.