Tibial Intramedullary Nail Fixation Technique

Intramedullary nail fixation inoramba iri kurapwa kwesarudzo yekusagadzikana uye kudzingwa tibial stem fractures muvakuru. Chinangwa chekurapa kwekuvhiya ndechekudzorera kureba, kurongeka uye kutenderera kwetibia uye kuwana kuporesa kuputsika. Zvakanakira zve intramedullary nailing ishoma kuvhiyiwa kukuvadzwa uye kuchengetedzwa kwakakodzera kweropa rekupa pakatyoka. Pamusoro pezvo, intramedullary nailing yetibia inopa kwakakodzera biomechanical fracture kugadzikana uye inoshanda seyakatakura-kugovera mudziyo inobvumira kutanga postoperative mobilization. Kufambira mberi mukugadzirwa kwezvipikiri zve intramedullary uye nzira dzekudzikisa kwakawedzera zviratidzo zve intramedullary nail fixation kuti ibatanidze proximal tibia uye yakadzika yepakati yechitatu kuputsika.

Kusvikira zuva ranhasi, kuvharwa kuderedzwa kwe intramedullary nail fixation ye tibial fractures yave yakajairika nzira yekukuvara kwemapfupa emapfupa. Pasinei nekuzivikanwa kwe intramedullary nail fixation ye displaced tibial stem fractures, inoramba ichinetsa uye ine matambudziko akawanda anogona kuitika. Nzira dzekuvhiya dzinoramba dzichichinja. Chinangwa chechinyorwa ichi ndechekutsanangura pfungwa dzazvino mu intramedullary mbambo kugadzirisa kwetibial stem fractures uye kupfupisa kufambira mberi kwazvino mumunda.

一. Kuongorora kwekutanga uye kuongorora

Muvarwere vaduku, tibial stem fractures inowanzova chikonzero chekukuvara kwepamusoro-simba, uye varwere vanofanira kuongororwa nokuda kwekushungurudzika kwakabatana maererano ne Advanced Trauma Life Support (ATLS) mirayiridzo. Ongorora kukuvara kwakatenderedza ganda uye zvinyoro zvinyoro kukuvara senge kuputsika mablisters, ganda mabrasions, kutsva, ecchymosis, kana kukwirira kweganda; kujekesa kana kuputsika kwakazaruka, uye kana zvakadaro tora tetanus nemishonga inorwisa mabhakitiriya; uye ita kunyatsoongorora neurovascular uye kunyora zviri pamusoro. Ongorora kuitika kwe osteofascial compartment syndrome uye ita nhevedzano yekiriniki bvunzo muvarwere ava.

Zvidzidzo zvenguva pfupi zvakaratidza kuti chiitiko che osteofascial compartment syndrome inotevera tibial tuberosity fractures inogona kunge yakakwira se11.5%. Kunyanya, mapoka madiki evarwere ane mukana wekuita osteofascial compartment syndrome. Kuongororwa kwe osteofascial compartment syndrome kunofanira kubva pane zvakawanikwa mumakiriniki, kusanganisira kurwadziwa kwakanyanya, neurovascular shanduko, kuputika kwemyofascial compartment, uye kuwedzera marwadzo kubva pakuwedzera zvigunwe. Naizvozvo, osteofascial compartment syndrome inoramba iri kiriniki yekuongororwa uye kunyatso magwaro ekuongororwa kwekiriniki kwakakosha. Dzvinyiriro mukati meiyo myofascial compartment inogona kuyerwa nenzira yekumanikidza tsono (Mufananidzo 1) senzira yekuwedzera yebvunzo kune yakakosha bvunzo.

Mufananidzo 1. Kuyera kwekumanikidza mu interosseous septum kuburikidza nesimbi yekumanikidza.

Kuti uwane data yakavimbika, intrafascial pressures inofanirwa kuyerwa mumakamuri mana emyofascial uye munzvimbo dzakasiyana mukati meimwe myofascial compartment. Zvidzidzo mumabhuku zvinoratidza kuti mutsauko wekumanikidza uri pasi pe30 mmHg (diastolic pressure minus fascial compartment pressure) inoratidza fascial compartment syndrome. Diastolic pressure inowanzodzikira panguva yekuvhiyiwa, uye preoperative diastolic pressure inofanirwa kuverengerwa pakuverenga kusiyanisa kumanikidza.

Zvidzidzo zvenguva pfupi yapfuura zvakaratidza kuti intrafascial pressure monitoring chishandiso chinogona kubatsira pakuongororwa kweacute fascial compartment syndrome, nekunzwa kwe94% uye 98%. Zvisinei, zvichipiwa migumisiro inogona kukuvadza ye compartment syndrome, kuongororwa kwecompartment syndrome kunofanira kubva pane zvakawanikwa mumakiriniki, uye interosseous compartment pressure measurements inofanira kushandiswa mumamiriro ezvinhu anokosha, akadai apo murwere akakuvadzwa kana kuti kliniki data points isinganzwisisiki.

Kuongororwa kwekufungidzira kunofanira kusanganisira maitiro eorthopantomograms uye maonero ekupedzisira etibia yakakuvadzwa uye radiographs yebvi riri pedyo uye majoini emakumbo, ayo anoongororwa zvakare achishandisa computed tomography (CT). Saizvozvo, CT scan yechidzitiro inogona kuve yakakosha kuti utarise mitsetse yekuputsika ichienda kune iyo tibial plateau uye inosanganisirwa noncontiguous ankle kukuvara.

二. Mitsipa yemakiriniki

Chikamu chepamusoro chekuputsika kwepakati nechepakati chetatu chetibia nemakumbo emakumbo zvakataurwa. Kushandisa CT scans, 43% yekuputsika kwepakati nepakati pechitatu yetibia yakaperekedzwa nekuputsika kwemakumbo, iyo yakawanda yaida kurapwa. Rudzi rwakawanda rwekuputsika rwakanga rwuri kuputsika kwemhepo yepakati yepakati yechitatu ye distal tibia yakabatana nechinguva chiduku kana chisina kubviswa shure kwegumbo remakumbo (Mufananidzo 2). Nekuda kwekutama kudiki kwekutyoka kwechidzitiro chakabatana, chete 45% yekukuvara inogona kuwonekwa pane plain ankle radiographs. Nokudaro, maitiro eC CT scans echidzitiro anofanira kunyanya kusimbiswa kana pasi repakati tibia fracture iripo (Fig. 3).

Mufananidzo 2.AF Spiral kutyoka kwechikamu chepakati chetatu chekurudyi chetibia (A, B) Preoperative radiographs yeankle show yakajairika (C). Intraoperative C-arm fluoroscopy inoratidza kusaputsika kusingagadzirwe kwechidzitiro cheshure (D) Postoperative radiographs mushure mekuvhiyiwa kugadzirisa (EF) inoratidza kuporeswa kwakanaka kwetibial uye ankle fractures.

Mufananidzo 3. AF Spiral kuputsika kwepakati uye nechetatu chetatu chekuruboshwe tibia (AB) preoperative radiographs; (CD) preoperative CT scans inoratidza nondisplaced posterior malleolar fracture; (EF) kuratidza kuporesa kusinganzwisisiki kwetibia uye malleolar fracture

三. Nzira dzokuvhiya

01. Tibial Needle Entry Point

Kugadzira nzvimbo yekupinda chaiyo inoita basa rakakosha uye zvidzidzo zvakawanda muzvinyorwa zvakapa ruzivo rwakakosha nezvenzvimbo yeanatomical yenzvimbo yakakodzera yekupinda yeintramedullary nailing yetibial fractures. Zvidzidzo izvi zvakaratidza kuti yakanakira pinning poindi iri kumucheto wepamberi wetibial plateau uye ingori pakati peiyo lateral tibial spur. Nzvimbo yekuchengetedza ine hupamhi hwe22.9 mm ± 8.9 mm, iyo isingakonzere kukuvadza kune ari padyo majoini zvimiro, yakashumwa zvakare. Nechinyakare, nzvimbo yekutanga ye intramedullary nail fixation ye tibial stem fractures yakasimbiswa kuburikidza ne infrapatellar approach, kana nekuparadzanisa patellar tendon (transpatellar approach) kana kubvisa chikamu che patellar tendon stop (paratendinous approach).

Semi-extension intramedullary nailing yakwezva kutarisisa zvakanyanya mumabhuku emapfupa echangobva kuitika, uye Tornetta naCollins vanokurudzira kushandisa nzira yepakati parapatellar yekugadziriswa kwemukati kwembambo munzvimbo yekuwedzera-yekuwedzera kudzivirira kubuda kweapex ye intramedullary chipikiri mu anterior tibial cortex yekushandiswa kwepakati nepakati. semi-extension chinzvimbo inokurudzirwa zvakare. Kushandiswa kwe suprapatellar nzira ye tibial intramedullary nailing uye kuiswa kwe intramedullary nail kuburikidza ne patellofemoral joint mu semi-extended position inokurudzirwa.

Iyo nzira inoitwa nemabvi akachinjika paanenge 15-20 madhigirii, uye longitudinal incision inosvika masendimita matatu inoitwa upamhi hwemunwe kusvika kuviri pamusoro pe patella. Iyo quadriceps tendon inopatsanurwa mune refu fashoni uye blunt dissection inoitwa muchikamu chepatellofemoral. Chigadziko chisina kujeka chinopindirwa kuburikidza nejojo ​​ye patellofemoral kuti iite nzvimbo yekupinda pamusangano we proximal anterior tibial cortex uye articular surface (Mufananidzo 4).

Mufananidzo 4. ab Intraoperative mifananidzo ye (a) kupatsanura quadriceps tendon uye kuisa trocar kuburikidza ne patellofemoral joint kusvika kune tibial entry point; (b) intraoperative lateral maonero ekupinda

Iyo 3.2 mm yekuboora bhiti inoshandiswa kuona panotangira tsono pasi peC-arm kutungamira. Socket ine perforated inopihwa kuti inyatso gadzirisa yekupinda nekubuda nayo. Iyo yakasara yekuvhiya maitiro anosanganisira reaming uye tibial chipikiri kuiswa kunoitwa kuburikidza nesoketi.

ZVINOGONA ZVINOGONA: Iyo semi-yakawedzerwa gumbo chinzvimbo chinogona kubatsira mukutyoka repositioning, kunyanya mukutyoka neyakajairwa proximal chetatu chetibia uye angled kumberi. , Iyo semi-yakawedzerwa chinzvimbo inogona kubvisa kushushikana pane quadriceps tsandanyama uye kubatsira mukuputsika repositioning. , The semi-extended position suprapatellar approach inogonawo kuva imwe nzira yetsika infrapatellar nzira (Mufananidzo 5).

Mufananidzo 5. Mufananidzo weIntraoperative unoratidza kukuvara kwenyama yakapfava munharaunda ye infrapatellar sechiratidzo chenzira ye suprapatellar mune imwe nzvimbo yakawedzerwa.

Zvidzidzo zvakaratidza kuti nzira ye suprapatellar kune tibial intramedullary nailing mune semi-yakawedzerwa chinzvimbo inzira yakachengeteka uye inoshanda yekuvhiya. Ramangwana remakiriniki miedzo inodiwa kuti uwedzere kuongorora zvakanakira nekuipira kwe suprapatellar nzira ye intramedullary nailing uye kuongorora mhedzisiro yenguva refu ine chekuita nehunyanzvi uhu.

02. Reset tekinoroji

Kuiswa kwetibial intramedullary nail chete hakuiti kuti kuderedzwa kwakakwana kwekuputsika; kudzikisira kwakaringana kwekutyoka kunofanirwa kuchengetedzwa mukati mekuita zvekare uye intramedullary chipikiri kuiswa. Iko kushandiswa kwemanyorero traction chete hakugone nguva dzose kuwana kuderedzwa kweanatomic kwekutyoka kwega. Ichi chinyorwa chinotsanangura zvakasiyana-siyana zvakavharwa, zvishoma zvinopinda, uye zvakavhurika kuderedza maneuvers.

-Yakavharwa reset tekinoroji mazano

Yakavharwa kuderedza kushandiswa kunogona kuitwa nemudziyo wekuderedza seF-fracture reducer, F-shaped radiographically transmissible reduction device inogadzirisa inversion / exversion angles pamwe chete neshanduro yemukati / lateral (Fig. 6).

Fig. 6. F-shaped fracture reducer inotaurwa mukuvhiya

Nekudaro, chishandiso chinogona kuisa kushushikana kwakanyanya pamatishu akapfava, uye kushandiswa kwenguva refu kweichi reset mudziyo kunofanirwa kudziviswa. Reduction forceps inogonawo kuiswa percutaneously, sezviri munyaya ye spiral uye oblique fractures. Zvishandiso izvi zvinogona kushandiswa nenzira yakapfava-tishu yehushamwari kuburikidza nediki diki (Mufananidzo 7).

Mufananidzo 7. Percutaneous clamping kugadzirisa zvakare tibial fracture

Rudzi rwechivharo uye nzvimbo yekuvhiya incision inofanira kusarudzwa zvichienderana nehurongwa hwekudzikisa kukuvadzwa kwenguva refu kune zvinyoro zvinyoro kubva pakuiswa kwe clamp (Mufananidzo 8).

Fig. 8. Yakanongedza repositioning forceps kugadzirisa zvakare tibial fracture

Retractors zvakare imwe yeakajairika reset maturusi anoshandiswa kudzorera kureba kune tibia. Vanowanzoiswa pakati uye kure nenzvimbo iyo intramedullary nail inoda kuiswa. Proximal traction pini inogona kuiswa kutevedzera proximal blocking screw chinzvimbo, iyo inobvumira kudzikisa nyore kwekutsemuka kana intramedullary chipikiri chapinda.

Mune zvimwe zviitiko, yakavharika uye zvishoma invasive kuderedza maitiro achiri asina kukwana kuwana kuderedzwa kweanatomic. Mumamiriro ezvinhu akadaro, maitiro ekuderedza maitiro anofanirwa kutariswa nekunyatsotarisirwa kwezvinyoro zvakapoteredza. Zvingangove zvakashata zvematanho ekudzikisa akavhurika anosanganisira kuwedzera kukuvadzwa kwekuvhiya, izvo zvinogona kuwedzera njodzi yekuvhiya nzvimbo yehutachiona. Mukuwedzera, kuwedzera kubviswa kweropa kune nzvimbo yekuputsika kunogona kuwedzera njodzi ye postoperative fracture nonunion.

-Technical Skills for Incision uye Repositioning

Incisional reduction maneuvers inobvumira kwete chete kuvhiya kudzikisa masimba akaiswa panzvimbo yakakodzera, asiwo kushandiswa kwediki kana diki diki panzvimbo yekutyoka kuchengetedza kuderedzwa kwekutyoka panguva ye intramedullary nailing maitiro.

Mahwendefa anochengetedzwa kune zvakapfuura uye distal fracture zvimedu uchishandisa monocortical screws. Iyo splint inochengetwa mukati mekuita kwekudzokorora uye kuiswa kweiyo intramedullary mbambo mutibia. Mushure mekuiswa kwembambo ye intramedullary, ndiro yakabviswa kana kuti yakasiiwa panzvimbo kuti iwedzere kugadzikana kwegadziriro yakagadziriswa (Mufananidzo 9). Nekusiya ndiro iri panzvimbo, iyo cortical screw inofanira kuchinjaniswa nekaviri cortical screw. Inofanira kutariswa kuti ishandiswe mumatambudziko akasarudzwa apo tibial stem inoda kuvhiyiwa kwakasununguka kuti iwane kuderedzwa kunogamuchirwa kwekuputsika.

Mufananidzo 9. Vhura tibia kuputsika nekugadzirisa kwakanyanya uye kukanganisa kwepfupa, imwe cortical fixation ine chidimbu chiduku pamucheto wakaputsika wekuputsika mushure mekuderedza uye kubviswa kwechitsiko mushure me intramedullary nail fixation.

Chinangwa chekuvharira chipikiri ndechekudzikisa medullary cavity munharaunda yemetaphyseal. Kuvhara zvipikiri zvinoiswa mukati mepfupi articular fragment uye kune concave side ye deformity isati yaiswa intramedullary chipikiri. Semuenzaniso, iyo yakajairwa kuremara kwekuputsika kweiyo proximal yechitatu yetibia inoratidzwa ne valgus uye mberi angulation. Kuti ugadzirise valgus deformity, chivharo chekuvhara chinogona kuiswa muchikamu chemashure chechikamu chepamusoro chekuputsika (kureva, rutivi rwe concave ye deformity) mune anteroposterior direction. Iyo intramedullary nail inotungamirirwa kubva kudivi remukati, nokudaro ichidzivirira valgus. Saizvozvo, angulation deformity inogona kukundwa nekuisa yekukiya screw medial kune lateral kune posterior chikamu cheproximal block (kureva, iyo concave side ye deformity) (Mufananidzo 10).

Mufananidzo 10. yakabatsira reset ye tibial fracture nekuiswa kwekuvhara zvipikiri

-Medullary kuwedzera

Mushure mekupedza kutsemuka repositioning, medullary reaming inosarudzwa kuti igadzirire bhonzo rekupinza intramedullary chipikiri. Iyo bhora-yakapera gwara rinopinzwa mukati metibial marrow mhango uye kuburikidza nenzvimbo yekutyoka, uye dhiraivha inopfuudzwa pamusoro pebhora-rakapera gwara. Nzvimbo yebhora-yakapera guidewire yakasimbiswa pasi peC-arm fluoroscopy kuti ive pamwero wejojo ​​remakumbo, uye gwara racho rakanga rakanyatsotarisa pane zvose anteroposterior uye lateral maonero (Mufananidzo 11).

Mufananidzo 11. inoratidza nzvimbo yeguidewire mu medullary cavity paC-arm fluoroscopy munzvimbo dzepamberi uye dzepashure.

Iyo nyaya yekuwedzera inopesana ne-isina-yakawedzera medulla yanga ichinetsa. Isu tinotenda kuti vazhinji vanovhiya muNorth America vanosarudza yakawedzera medullary intramedullary nailing yetibia kune isina-yakawedzerwa. Nekudaro, zvese zvakawedzerwa uye zvisina kuwedzeredzwa intramedullary nailing zvinogona kushandiswa seanogamuchirwa chiyero maitiro, uye mhedzisiro yakanaka inogona kuwanikwa nenzira mbiri.

-Kukiya sikuruu kuiswa

Kushandiswa kwezvisungo zvakavharidzirwa mu tibial stem fractures inotarisirwa kudzivirira kupfupisa uye kukanganisa, kuwedzera zviratidzo zve intramedullary nailing ye tibia kune mamwe maproximal uye distal tibial stem fractures anosanganisira metaphysis. Mukutsemuka kunosanganisira metaphyseal nharaunda, kupindirana screws kwakave kwakakosha mukuchengetedza axial alignment.

Zvisururu zvitatu zvakapindika zvakanatsiridza kugadzikana, uye makona-yakadzikama anovharira screws anogona kupa kugadzikana kwakakura kupfuura akajairwa anovharira screws, izvo zvinogona kubvumira imwechete kugadzikana kwechimiro kuwanikwa nenhamba diki yeakavharira screws. Clinical data pamusoro penhamba uye kugadziridzwa kwezviputi zvinopindirana zvinodiwa kuti mukati mekugadzirisa tibia zvirambe zvisingakwanisi.

Kuiswa kweproximal interlocking screws kunowanzoitwa uchishandisa scope yakasungirirwa kune intramedullary nail spike. Distal interlocking screws anoiswa freehand pasi pe fluoroscopic kutungamira. Kushandiswa kwe electromagnetic komputa-inobatsira kutungamira system inokurudzirwa kuisa distal tibial interlocking screws (Mufananidzo 12). Iyi tekinoroji inobvumira kuiswa-isina radiation kuisirwa distal interlocking screws uye yakaratidza kuti inzira inogoneka uye yakarurama.

Mufananidzo 12.AB Kukiya screws kuburikidza neC-arm maonero; CD Locking screws kuburikidza ne electromagnetic komputa-inobatsira kukiya

Kuiswa kweproximal uye distal interlocking screws inzira yakachengeteka yekuvhiya uye masiruu anovharirana anofanira kuiswa nenzira chaiyo uye yakapfava ine hushamwari.

Zvidzidzo zveAnatomic zvakaratidza kuti pachine njodzi yeperoneal nerve palsy kana uchiisa proximal medial kune lateral oblique interlocking screws. Kuti uderedze njodzi iyi, vanachiremba vanovhiya vanofanirwa kufunga nezvekuchera ma screws pasi peC-arm kutungamira, ine fluoroscopic angle yeC-arm perpendicular kune ndege yekubooresa. Drill kupinda mu cortex ye distal tibia inogona kuva yakaoma kuona ne tactile mhinduro, uye kuswedera pedyo kwemusoro wefibula kunogona kuvharidzira tactile mafungiro uye kupa chiremba anovhiya pfungwa yekuve 'mupfupa' apo chaizvoizvo musoro wefibula wakapindwa. Kureba kwe screw hakufanirwe kutariswa kwete chete nechibooreso chapedza kudzidza asiwo nezviyero zvakadzika zvegeji. Chero chibooreso kana sikuruu urefu huyero hunopfuura 60 mm hunofanira kusimudzira kufungirwa kweposterolateral protrusion, iyo inogona kuisa iyo yakajairika peroneal nerve panjodzi yekukuvara.

Distal anterior and posterior interlocking screws anoiswa nehanya nekuchengetedzwa kweanterolateral neurovascular bundle, tibialis anterior tendon, uye extensor digitorum longus. Kunyangwe percutaneous screw placement kazhinji yakachengeteka, vanachiremba vanovhiya vanofanirwa kuziva nezve njodzi kune dzakatenderedza zvinyoro zvinyoro zvimiro. Kune akawanda tibial stem fractures, maviri proximal uye maviri distal interlocking screws anopa kugadzikana kwakakwana. Proximal uye distal tibial fractures inogona kubatsirwa kubva pakuiswa kwezvimwe zvivharo zvinopindirana mundege dzakasiyana-siyana kuti kuwedzere kugadzikana kwechimiro ichi (Mufananidzo 13).

Mufananidzo 13. Kutyoka kwakawanda kwetibia, kunorapwa ne intramedullary nailing ne distal maviri uye matatu proximal interlocking screws, neakazotevera x-rays inoratidza kuporeswa kwekutyoka.

-Fibular Fixation

Contemporary intramedullary mbambo madhizaini ane distal interlocking screws akawedzera zviratidzo zvekurovererwa kwe intramedullary yetibia kuti ibatanidze proximal uye distal fractures inosanganisira metaphyseal dunhu.

Different distal interlocking screw configurations akashandiswa muchidzidzo (2 screws kubva pakati kusvika lateral versus 2 screws akaiswa perpendicular kune mumwe nemumwe uye inokwana 3 distal interlocking screws maringe chete 1 distal interlocking screw). Mune varwere vakawana fibular fixation uye tibial intramedullary nail fixation, chiyero chekurasika chekugadzirisa chakanga chakanyanya kuderera. Chikamu che13% chevarwere vane intramedullary nail fixation pasina fibular fixation yakaratidza kurasikirwa kwepashure kwekugadzirisa, zvichienzaniswa ne4% yevarwere vane tibial nail fixation pasina fibular fixation.

Mune imwe muedzo uchienzanisa kushanda kwetibial intramedullary nail fixation inopesana nefibular fixation uye tibial intramedullary nail fixation versus no fibular fixation, varwere vanobatwa nefibular fixation pamwe chete netibial nailing vakaratidza kuvandudzwa mukutenderera uye inversion / eversion alignment.

Isu tinogumisa kuti adjunctive fibular fixation inobudirira uye inochengetedza tibial fracture kuderedzwa mu distal imwe-chetatu tibia fractures inopinda intramedullary nail fixation. Zvisinei, dambudziko rematambudziko ekukuvadzwa kubva kune mamwe maitiro munzvimbo yezvinyama zvakakuvadzwa zvinoramba zviripo. Saka isu tinokurudzira kuchenjerera mukushandiswa kwekubatsira fibular fixation.

03. Migumisiro

Intramedullary nailing fixation yetibial stem fractures inogona kuunza mhedzisiro yakanaka. Kuporesa mazinga e intramedullary nailing yetibia zvakataurwa mune zvidzidzo zvakasiyana. Nekushandiswa kwemazuva ano ma implants uye nzira dzekuvhiya dzakakodzera, mitengo yekuporesa inotarisirwa kudarika 90%. Kuporeswa kwetibial stem fractures iyo yakakundikana kupora mushure me intramedullary nail fixation yakagadziridzwa zvinoshamisa mushure mekugadzirisa kwemukati nechechipiri yakawedzerwa intramedullary nail.

Kuongororwa kwemigumisiro kune rimwe gore mushure mekuvhiyiwa kwakaratidza kuti kusvika ku44% yevarwere vakaramba vaine zvisingakwanisi kushanda mumusana wakakuvara, uye kusvika ku47% vakaramba vachirondedzera kuremara kwakabatana nebasa mugore rimwe mushure mekuvhiyiwa. Chidzidzo chacho chinoratidza kuti varwere vanobatwa ne intramedullary nailing ye tibia vanoramba vaine zvipingamupinyi zvakakosha zvekushanda munguva refu. Vanachiremba vanovhiya vanofanira kuziva nezvenyaya idzi uye vanorayira varwere maererano!

四. Postoperative matambudziko

01. Pre-patellar kurwadziwa

Anterior patellofemoral kurwadziwa chinhu chinowanzoitika mushure me intramedullary nail fixation ye tibial stem fractures. Zvidzidzo zvakaratidza kuti inenge 47% yevarwere mushure me intramedullary nailing inogona kukura prepatellar pain, iyo etiology iyo isinganyatsonzwisiswi. Zvinogona kukanganisa zvikonzero zvinogona kusanganisira kukuvadza uye kukuvadza kwehutano kune zvivakwa zve-intra-articular, kukuvadzwa kune infrapatellar bazi re saphenous nerve, kushaya simba kwehudyu mhasuru yechipiri kusvika pakudzvinyirirwa kwemarwadzo ane chokuita neuromuscular reflexes, fibrosis yemafuta pad inotungamirira mukupingement, reactive patellar tendonitis, kupfugama pamusoro pechikamu cheproduximal uye kupfugama kubuda kweparutivi pekupedzisira kwembambo.

Paunenge uchidzidza etiology ye prepatellar pain mushure me intramedullary nailing, iyo transpatellar tendon nzira yakafananidzwa neparapatellar nzira. Iyo transpatellar tendon nzira inogona kusanganiswa nehuwandu hwepamusoro hwekurwadziwa kwemabvi mushure mekushanda. Zvisinei, dhiyabhorosi yekliniki data haina kuratidza kusiyana kukuru pakati pe transpatellar tendon nzira uye nzira yeparapatellar.

Kubudirira kwekusarudza kubviswa kwekugadzirisa kwemukati kugadzirisa kurwadziwa kweprepatellar mushure metibial intramedullary nailing haina chokwadi. Isu tinokurudzira kuti kubviswa kweiyo intramedullary tibial nail kutariswe kana mechanical etiology inogona kuzivikanwa, senge mbambo yezvipikiri kana dhizaini inopindirana screw. Zvisinei, kubatsirwa kwetibial intramedullary nail kubviswa muvarwere vane zviratidzo zvinoramba zvisina mubvunzo.

Nezve postoperative prepatellar pain, chikonzero chemarwadzo hachikwanisi kuratidzirwa zvakajeka mukutanga kwekliniki yekuongorora ye intramedullary nail fixation ye tibial nail pa patella munzvimbo yehafu-yakawedzerwa. Nokudaro, zvidzidzo zvekliniki zvakakura nekutevera kwenguva refu zvakakosha kuti usimbise mhedzisiro ye intramedullary nail fixation mu suprapatellar approach pa postoperative prepatellar pain.

02.Poor postoperative alignment

Post-traumatic osteoarthritis inoramba iri dambudziko rakakura mushure mekurapa tibial stem fractures ne intramedullary nailing. Zvidzidzo zveBiomechanical zvakaratidza kuti tibial malalignment inogona kukonzera kuchinja kukuru muhutano hwekubatana pamakumbo emakumbo uye mabvi.

Zvidzidzo zvemakiriniki zvinoongorora mhedzisiro yenguva refu yekiriniki uye yekufungidzira mushure mekuputsika kwetibial stem kwakapa data rinopesana pane sequelae yetibial malalignment, pasina mhedziso dzakajeka kusvika nhasi.

Mishumo ye postoperative malalignment mushure me intramedullary nailing ye tibia inoramba iine zvishoma, ine nhamba shomanana yezviitiko zvinoshumwa. Postoperative malrotation inoramba iri dambudziko rinowanzoitika mu tibial intramedullary nailing, uye intraoperative assessment ye tibial rotation inoramba ichinetsa. Kusvika iye zvino, hapana kuongororwa kwekiriniki kana nzira yekufungidzira yakasimbiswa seyero yegoridhe yekushanda kwekutsvaga kwetibial rotation.CT kuongororwa kwekuongorora kwakaratidza kuti chiyero chekushaya simba mushure me intramedullary nailing yetibia inogona kunge yakakwirira se19% kusvika 41%. Kunyanya, kuremara kwekutenderera kwekunze kunoratidzika kunge kwakajairika pane kuremara kwekutenderera kwemukati. Kuongororwa kwekliniki yekuongorora postoperative malrotation yakanzi yakanga isina kururama uye yakaratidza kuwirirana kwakaderera neCT assessment.

Isu tinotenda kuti malalignment inoramba iri dambudziko renguva refu mune tibial stem fractures inobatwa ne intramedullary nailing yetibia. Pasinei nemashoko anopikisana maererano nehukama huri pakati pekusagadzikana uye kliniki nemigumisiro yekufungidzira, tinokurudzira kuti vanachiremba vanovhiya vanofanira kuedza kuzadzisa anatomic alignment yekuputsika kuitira kudzora kuchinja uku uye kuwana migumisiro yakakwana.

五. Mhedziso

Static kukiya yakawedzera medullary intramedullary nailing inoramba iri iyo yakajairwa kurapwa kweakadzingwa tibial stem fractures. Nzvimbo yakarurama yekupinda inoramba iri chikamu chakakosha chekuvhiya. Iyo suprapatellar nzira mune semi-yakawedzerwa chinzvimbo inoonekwa seyakachengeteka uye inoshanda maitiro, uye zvidzidzo zvenguva yemberi zvinoda kuenderera mberi nekuongorora njodzi uye zvakanakira nzira iyi. Chiremba anovhiya anofanirwa kunge achijairana nemaitiro emazuva ano ekugadzirisa zvakare. Kana anatomic fracture alignment isingawanikwe kuburikidza neyakavharika nzira, incisional yekudzikisa matekiniki inofanirwa kutariswa. Kupora kwakanaka kweanodarika 90% kunogona kuwanikwa neakawedzera uye asina-akawedzera intramedullary nailing. Pasinei nemaitiro akanaka ekuporesa, varwere vachine nguva refu yekushanda. Kunyanya, kurwadziwa kweprepatellar kunoramba kuri kunyunyuta kwakajairika mushure metibial intramedullary nailing. Mukuwedzera, kukanganisa mushure mekugadzirisa kwemukati tibial kunoramba kuri dambudziko rinowanzoitika.

References

1.Study to Prospectively Evaluate Reamed Intramedullary Nails muVarwere vane Tibial Fractures Investigators. Bhandari M, Guyatt G, Tornetta P, III, Schemitsch EH, Swiontkowski M, et al. Randomized muedzo we remed uye unreamed intramedullary nailing ye tibial shaft fractures. J Bone Joint Surg Am. 2008;90:2567–2578. doi: 10.2106/JBJS.G.01694.

2.McQueen MM, Duckworth AD, Aitken SA, Sharma R, Court-Brown CM. Predictors of compartment syndrome mushure mekuputsika kwetibial. J Orthop Trauma. 2015. [Epub pamberi pekudhindwa].

3.Park S, Ahn J, Gee AO, Kuntz AF, Esterhai JL. Compartment syndrome mu tibial fractures. J Orthop Trauma. 2009;23:514–518. doi: 10.1097/BOT.0b013e3181a2815a.

4.McQueen MM, Dare-Brown CM. Kuongorora kwekamuri mu tibial fractures. Iyo yekumanikidza chikumbaridzo che decompression. J Bone Joint Surg (Br) 1996;78:99–104.

5.McQueen MM, Duckworth AD, Aitken SA, Court-Brown CM. Iyo inofungidzirwa senitivity uye kujeka kwecompartment pressure monitoring yeacute compartment syndrome. J Bone Joint Surg Am. 2013;95:673–677. doi: 10.2106/JBJS.K.01731.

6.Whitesides TE, Jr, Haney TC, Morimoto K, Harada H. Tissue pressure measurements sechikonzero chekudiwa kwefasciotomy. Clin Orthop. 1975;113:43–51. doi: 10.1097/00003086-197511000-00007.

7.Kakar S, Firoozabadi R, McKean J, Tornetta P., 3rd Diastolic blood pressure kune varwere vane tibia fractures pasi peanesthesia: zvinokonzerwa nekuongororwa kwecompartment syndrome. J Orthop Trauma. 2007;21:99–103. doi: 10.1097/BOT.0b013e318032c4f4.

8.Purnell GJ, Glass ER, Altman DT, Sciulli RL, Muffly MT, Altman GT. Migumisiro ye computed tomography protocol inoongorora distal yechitatu tibial shaft fractures kuongorora noncontiguous malleolar fractures. J Trauma. 2011;71:163–168. doi: 10.1097/TA.0b013e3181edb88f.

9.Buehler KC, Green J, Woll TS, Duwelius PJ. Nzira ye intramedullary nailing ye proximal yechitatu tibia fractures. J Orthop Trauma. 1997;11:218–223. doi: 10.1097/00005131-199704000-00014.

10.McConnell T, Tornetta P, III, Tilzey J, Casey D. Tibial portal placement: radiographic correlate yenzvimbo yakachengeteka yeanatomic. J Orthop Trauma. 20

01;15:207–209. doi: 10.1097/00005131-200103000-00010 .etc......