Thekiniki yo Tiyisa Swipikiri ya Tibial Intramedullary

Intramedullary nail fixation yitshama yiri vutshunguri bya nhlawulo eka ku tshoveka ka nsinya wa tibial lowu nga tshamisekangiki na lowu rhurheriweke eka vanhu lavakulu. Xikongomelo xa vutshunguri bya vuhandzuri i ku vuyisela ku leha, ku ringanana na ku rhendzeleka ka tibia na ku fikelela ku hola ka ku tshoveka. Swipfuno swa intramedullary nailing i ku vaviseka kutsongo ka vuhandzuri na ku hlayisiwa loku faneleke ka mphakelo wa ngati eka ku tshoveka. Ku engetela kwalano, intramedullary nailing ya tibia swinyika kutshamiseka loku faneleke ka biomechanical fracture naswona switirha tani hi xitirhisiwa xo avelana ndzhwalo lexi pfumelelaka ku hlengeletiwa ka xihatla endzhaku ka vuhandzuri. Nhluvuko eka dizayini ya swipikiri swa le ndzeni ka medullary na tindlela to hunguta swi ndlandlamuxe swikombiso swa ku khomiwa ka swipikiri swa le ndzeni ka medullary ku katsa na tibia ta le kusuhi na ku tshoveka ka le hansi ka vunharhu bya le xikarhi.

Ku fikela namuntlha, closed reduction intramedullary nail fixation ya tibial fractures yi hundzuke endlelo leri tolovelekeke eka madokodela ya vuhandzuri bya marhambu ya trauma. Hambi leswi ku dumeke ka intramedullary nail fixation eka displaced tibial stem fractures, switshama swiri ntlhontlho naswona swina swiphiqo swotala leswinga vaka kona. Maendlelo ya vuhandzuri ma ya emahlweni ma hluvuka. Xikongomelo xa xihloko lexi i ku hlamusela miehleketo ya sweswi eka intramedullary nail fixation ya tibial stem fractures na ku katsakanya nhluvuko wa sweswinyana eka ntirho lowu.

一. Ku kamberiwa ko sungula na ku kamberiwa

Eka vavabyi lavatsongo, ku tshoveka ka nsinya wa tibial hakanyingi ku vangiwa hi ku vaviseka ka matimba lamakulu, naswona vavabyi va fanele ku kamberiwa eka khombo leri fambelanaka na swona hi ku ya hi swiletelo swa Nseketelo wa Vutomi bya Makhombo ya le Henhla (ATLS). Kambisisa ku vaviseka ka nhlonge leyi rhendzeleke na tinyama to olova ku fana na swirhumbana swa ku tshoveka, ku rhurhumela ka nhlonge, ku hisiwa, ecchymosis, kumbe ku tlakuka ka nhlonge; hlamusela loko ku tshoveka ku pfulekile, naswona loko swi ri tano tshungula hi tetanus na swidlaya-switsongwatsongwana; naswona u endla nkambisiso lowu heleleke wa misiha ya misiha naswona u tsala leswi nga laha henhla. Kambisisa ku humelela ka osteofascial compartment syndrome naswona u endla nxaxamelo wa swikambelo swa tliliniki eka vavabyi lava.

Mindzavisiso ya sweswinyana yi kombisile leswaku ku humelela ka osteofascial compartment syndrome endzhaku ka ku tshoveka ka tibial tuberosity swinga va ehenhla kuya fika eka 11.5 %. Ngopfu-ngopfu, mintlawa ya vavabyi lavatsongo yi tala ku khomiwa hi vuvabyi bya osteofascial compartment syndrome. Ku kumiwa ka osteofascial compartment syndrome ku fanele ku seketeriwa eka swikumiwa swa tliliniki, ku katsa na ku vava lokukulu, ku cinca ka misiha ya misiha, ku pfimba ka xiyenge xa ​​myofascial, na ku tlakuka ka switlhavi ku suka eka ku andzisiwa ka swikunwana leswi nga tirhiki. Hikwalaho, osteofascial compartment syndrome yi tshama yi ri vukamberi bya tliliniki naswona ku tsariwa loku heleleke ka ku kamberiwa ka tliliniki i ka nkoka. Ntshikelelo endzeni ka xiyenge xa ​​myofascial wu nga pimiwa hi ku tirhisa naliti ya ntshikelelo (Xifaniso 1) tanihi ndlela yo engetela yo kambela eka xikambelo xo hlawuleka.

Xifaniso 1. Ku pimiwa ka ntshikelelo eka septum ya interosseous hi ku tirhisa naliti ya ntshikelelo

Ku kuma datha leyi tshembekaka, ntshikelelo wa le ndzeni ka fascial wu fanele ku pimiwa eka swiyenge swa mune swa myofascial na le ka tindhawu to hambana endzeni ka xiyenge xin’wana na xin’wana xa myofascial. Mindzavisiso eka matsalwa yi ringanyeta leswaku ku hambana ka ntshikelelo wale hansi ka 30 mmHg (ntshikelelo wa diastolic minus fascial compartment pressure) swikomba fascial compartment syndrome. Ntshikelelo wa diastolic hi ntolovelo wu hunguteka hi nkarhi wa vuhandzuri, naswona ntshikelelo wa diastolic wa le mahlweni ka vuhandzuri wu fanele ku tekeriwa enhlokweni loko ku hlayiwa ntshikelelo wa ku hambana.

Mindzavisiso ya sweswinyana yi kombisile leswaku ku langutisisa ntshikelelo wa intrafascial i xitirhisiwa lexi nga pfunaka eka ku kambela acute fascial compartment syndrome, na ku twisisa ka 94 % na ku kongoma ka 98 %. Hambiswiritano, loko ku nyikiwa vuyelo lebyi nga onhaka bya vuvabyi bya xiyenge, ku kumiwa ka vuvabyi bya xiyenge ku fanele ku seketeriwa eka leswi kumiweke eka tliliniki, naswona mimpimo ya ntshikelelo wa xiyenge xa ​​le xikarhi ka marhambu yi fanele ku tirhisiwa eka swiyimo swo hlawuleka, swo tanihi loko muvabyi a vavisekile kumbe loko tinhla ta datha ya tliliniki ti nga ri erivaleni.

Ku kamberiwa ka swifaniso ku fanele ku katsa ti orthopantomograms leti tolovelekeke na mavonelo ya le tlhelo ya tibia leyi vavisekeke na ti radiographs ta mahlangano ya matsolo na mavoko lama nga ekusuhi, leswi yaka emahlweni swi kamberiwa hi ku tirhisa computed tomography (CT). Hilaha ku fanaka, CT scan ya xirhendze yi nga ha laveka ku vona hi mahlo ya mianakanyo milayeni ya ku tshoveka leyi hangalakaka ku ya fika eka tibial plateau ni ku vaviseka ka xirhendze loku nga fambisaniki loku fambisanaka na kona

二. Swihinga swa vutshunguri

Tiphesente ta le henhla ta ku tshoveka ka xiphemu xa vunharhu xa le hansi xa le xikarhi xa tibia na ku tshoveka ka mavoko ti vikiwile. Hi ku tirhisa ti CT scan leti tolovelekeke, 43 % wa ku tshoveka ka xiphemu xa vunharhu xa le xikarhi na xa le hansi xa tibia a swi fambisana na ku tshoveka ka mavoko, laha vunyingi bya swona a swi lava vutshunguri bya vuhandzuri. Muxaka lowu tolovelekeke swinene wa ku tshoveka a ku ri ku tshoveka ka spiral ka xiphemu xa vunharhu xa le hansi xa le xikarhi xa tibia ya le kule lexi fambelanaka na ku tshoveka ka xirhendze xa le ndzhaku lexi nga rhurhisiwangiki nyana kumbe lexi nga rhurhisiwangiki (Xifaniso 2). Hikwalaho ka ku rhurha lokuntsongo ka ku tshoveka ka mavoko loku fambelanaka, i 45 % ntsena wa ku vaviseka loku nga voniwaka eka ti radiographs ta mavoko leti nga riki na nchumu. Hikwalaho, swikambelo swa ntolovelo swa CT swa xirhendze swi fanele ku kandziyisiwa swinene loko ku tshoveka ka tibia ya le hansi ya le xikarhi ku ri kona (Fig. 3).

Xifaniso 2.AF Ku tshoveka ka xirhendzevutani ka xiphemu xa vunharhu xa le hansi xa le xikarhi xa tibia ya xinene (A, B) Tiradiyogirafu ta le mahlweni ka vuhandzuri ta xirhendze ti kombisa ntolovelo (C). Intraoperative C-arm fluoroscopy yi kombisa ku tshoveka loku nga rhurhisiwangiki ka xirhendze xa le ndzhaku (D) Ti radiographs ta le ndzhaku ka vuhandzuri endzhaku ka vuhandzuri fixation (EF) ti kombisa ku hola loku rhetaka ka ku tshoveka ka tibial na ankle

Xifaniso 3. AF Ku tshoveka ka xirhendzevutani ka xiphemu xa vunharhu xa le xikarhi na xa le hansi xa tibia ta ximatsi (AB) preoperative radiographs; (CD) swifaniso swa CT swa le mahlweni ka vuhandzuri leswi kombisaka ku tshoveka ka malleolar ya le ndzhaku loku nga rhurhisiwangiki; (EF) leswi kombisaka ku hola loku nga humelelangiki ka tibia na ku tshoveka ka malleolar

三. Maendlelo ya vuhandzuri

01. Ndhawu yo Nghena eka Naliti ya Tibial

Ku simeka ndzhawu yo nghena leyi kongomeke swi tlanga xiave xa nkoka naswona tidyondzo to tala eka matsalwa ti nyikile vuxokoxoko bya nkoka eka ndzhawu ya anatomical ya ndzhawu leyinene yo nghena eka intramedullary nailing ya tibial fractures. Mindzavisiso leyi yi kombisile leswaku ndzhawu ya kahle ya pinning yi kumeka eka margin yale mahlweni ya tibial plateau naswona yi kumeka ntsena exikarhi kuya eka lateral tibial spur. Ndzhawu ya vuhlayiseki leyingana ku anama ka 22.9 mm ± 8.9 mm, leyinga vangiki ku onhaka eka swivumbeko swa nhlangano leswinga ekusuhi, na yona yi vikiwile. Hi ndzhavuko, ndzhawu yosungula ya intramedullary nail fixation ya tibial stem fractures yi simekiwile hiku tirhisa infrapatellar approach, kungava hiku avanyisa patellar tendon (transpatellar approach) kumbe hiku hluvula xiphemu xa patellar tendon stop (paratendinous approach).

Semi-extension intramedullary nailing yi koke nyingiso lowukulu eka matsalwa ya sweswinyana ya orthopatellar, naswona Tornetta na Collins va ringanyeta ku tirhisa endlelo ra parapatellar ra le xikarhi eka ku khomiwa ka le ndzeni ka xipikiri eka xiyimo xa semi-extension ku papalata ku huma ka apex ya xipikiri xa intramedullary eka anterior tibial cortex.3 Ku tirhisiwa ka ndlela ya parapatellar ya le xikarhi eka intramedullary nailing eka xiyimo xa semi-extension na swona swa hlohleteriwa. Ku tirhisiwa ka ndlela ya suprapatellar eka tibial intramedullary nailing na ku nghenisiwa ka xipikiri xa intramedullary hi ku tirhisa patellofemoral joint eka xiyimo xa semi-extended swa hlohleteriwa.

Endlelo leri ri endliwa hiku gombonyoka matsolo kwalomu ka 15-20 degrees, naswona ku tsemiwa hiku leha ka kwalomu ka 3 centimeters ku endliwa kwalomu ka ku anama ka rintiho rin’we kuya eka timbirhi ehenhla ka patella. Quadriceps tendon yi avanyisiwile hi ndlela yo leha naswona blunt dissection yi endliwa eka patellofemoral joint. Socket yo blunt yi nghenisiwa hi patellofemoral joint ku endla ndzhawu yo nghena eka nhlangano wa proximal anterior tibial cortex na articular surface (Xifaniso 4).

Xifaniso 4. ab Swifaniso swa le ndzeni ka vuhandzuri swa (a) ku avanyisa tendon ya quadriceps na ku nghenisa trocar hi ku tirhisa nhlangano wa patellofemoral ku ya eka ndhawu yo nghena ya tibial; (b) xivono xa le tlhelo xa le ndzeni ka vuhandzuri xa ndhawu yo nghena

Drill bit ya 3.2 mm yitirhisiwa ku kumisisa ndzhawu yosungula ya needle ehansi ka nkongomiso wa C-arm. Socket leyi pfulekeke yi nyikiwile ku lulamisa kahle tindzhawu to nghena na to huma. Maendlelo ya vuhandzuri lawa yanga sala kukatsa na reaming na tibial nail insertion ya endliwa hiku tirhisa socket.

SWIVUMBEKO SWA SWIVUMBEKO: Xiyimo xa milenge lexi nga andzisiwa hi xiphemu xi nga pfuneta eka ku vekiwa nakambe ka ku tshoveka, ngopfu-ngopfu eka ku tshoveka loku nga na xiphemu xa vunharhu xa le kusuhi lexi tolovelekeke xa tibia naswona xi angled forward. , Xiyimo lexi andlariweke hi xiphemu xi nga ha herisa ku tsana eka misiha ya quadriceps naswona xi pfuneta eku vekeni nakambe ka ku tshoveka. , Endlelo ra semi-extended position suprapatellar ri nga ha tlhela ri va ndlela yin’wana eka endlelo ra ndhavuko ra infrapatellar (Xifaniso 5).

Xifaniso 5. Xifaniso xa le ndzeni ka vuhandzuri lexi kombisaka ku vaviseka ka tinyama to olova eka ndhawu ya infrapatellar tanihi xikombiso xa ndlela ya suprapatellar eka xiyimo xa semi-extended.

Mindzavisiso yi kombisile leswaku endlelo ra suprapatellar eka tibial intramedullary nailing eka xiyimo xa semi-extended i endlelo ra vuhandzuri leri hlayisekeke no tirha kahle. Swikambelo swa tliliniki swa nkarhi lowu taka swa laveka ku ya emahlweni ku lavisisa swipfuno na ku biha ka suprapatellar approach intramedullary nailing na ku kambela mimbuyelo ya nkarhi wo leha leyi fambelanaka na thekiniki leyi.

02. Seta thekinoloji nakambe

Ku vekiwa ka xipikiri xa tibial intramedullary ntsena aswi endli leswaku kuhunguteka ku tshoveka loku ringaneleke; kuhungutiwa loku faneleke ka ku tshoveka swifanele ku hlayisiwa eka maendlelo hinkwawo ya reaming xikan’we naku vekiwa ka swipikiri endzeni ka medullary. Ku tirhisiwa ka manual traction ntsena swinga endleka kungari minkarhi hinkwayo ku fikelela kuhungutiwa ka anatomic ka ku tshoveka hi koxe. Xihloko lexi xi ta hlamusela tindlela to hambana-hambana to hunguta swilo leswi pfalekeke, leswi nga ngheneriki ngopfu ni leswi pfulekeke.

-Switsundzuxo swa thekiniki ya reset leyi pfalekeke

Ti manoeuvres to hunguta leti pfalekeke tinga endliwa hi xitirhisiwa xo hunguta kufana na F-fracture reducer, xitirhisiwa xo hunguta lexi hundziseriwaka hi radiographically xa xivumbeko xa F lexi lulamisaka ti inversion/exversion angles xikan’we na vuhundzuluxi bya medial/lateral (Fig. 6).

Fig. 6. Xihunguti xa ku tshoveka xa xivumbeko xa F lexi tshahiweke eka vuhandzuri

Hambiswiritano, xitirhisiwa lexi xi nga veka ntshikilelo lowukulu eka tinyama to olova, naswona ku tirhisiwa nkarhi wo leha ka xitirhisiwa lexi xo tlherisela swilo swi fanele ku papalatiwa. Ti reduction forceps tinga tlhela ti vekiwa hi percutaneously, tani hileswi swinga eka spiral na oblique fractures. Switirhisiwa leswi swinga cheriwa hindlela ya xinghana na ti soft-tissue hiku tirhisa swiphemu leswintsongo leswi tsemiweke (Xifaniso 7).

Xifaniso 7. Ku khomiwa hi percutaneous ku tlherisela ku tshoveka ka tibial

Muxaka wa clamp na ndzhawu ya vuhandzuri bya incision swifanele ku hlawuriwa kuya hi maqhinga yo hunguta ku onhaka ka nkarhi woleha eka ti soft tissues kusuka eka ku vekiwa ka clamp (Figure 8).

Fig. 8. Ti forceps to tlherisela eka xiyimo lexi kongomeke ku tlherisela ku tshoveka ka tibial

Ti retractors na tona i xin’wana xa switirhisiwa leswi tolovelekeke swo tlherisela swilo leswi tirhisiwaka ku vuyisela ku leha eka tibia. Hi ntolovelo ti vekiwa exikarhi nale kule na ndzhawu leyi xipikiri xa intramedullary xi lavaka ku vekiwa eka yona. Ti proximal traction pins tinga vekiwa kuva ti tekelela xiyimo xa proximal blocking screw, leswi pfumelelaka kuhungutiwa hiku olova ka ku tshoveka loko se intramedullary nail yiri endzeni.

Eka swiyimo swin’wana, tindlela to hunguta leti pfalekeke na leti nga ngheneriki ngopfu ta ha enelangi ku kuma ku hunguta ka anatomic. Eka swiyimo swo tano, tindlela to hunguta ku tsemiwa ti fanele ku tekeriwa enhlokweni hi vulawuri bya vukheta bya tinyama to olova leti rhendzeleke. Swiphiqo leswi nga vaka kona swa tindlela to hunguta ku pfuleka swi katsa ku vaviseka loku engetelekeke ka vuhandzuri, loku nga engetelaka khombo ra ku tluleriwa endhawini ya vuhandzuri. Ku engetela kwalaho, ku hluvuriwa loku engetelekeke ka mphakelo wa ngati eka ndhawu leyi ku tshovekeke ku nga ha engetela khombo ra ku nga hlanganisiwanga ka ku tshoveka endzhaku ka vuhandzuri.

-Vuswikoti bya Xithekiniki byo Tsema na ku veka hi vuntshwa

Ti incisional reduction maneuvers ati pfumelela ntsena ti surgical reduction forceps leti vekiweke eka ndzhawu leyi faneleke, kambe naku cheriwa ka ti splints letintsongo kumbe letintsongo eka ndzhawu ya fracture ku hlayisa kuhunguteka ka fracture hinkarhi wa maendlelo ya intramedullary nailing.

Ti plates ti khomiwa eka swiphemu swa proximal na distal fracture hiku tirhisa ti screws ta monocortical. Splint yi hlayisiwa eka maendlelo hinkwawo ya reaming naku vekiwa ka intramedullary nail eka tibia. Endzhaku ko vekiwa ka xipikiri xa intramedullary, plate yi susiwile kutani yi tshikiwa yi ri endhawini ya yona ku ndlandlamuxa ku tiya ka xivumbeko lexi nga cinciki (Xifaniso 9). Hiku siya plate yiri endhawini ya yona, single cortical screw yifanele ku cinciwa na double cortical screw. Yifanele ku tekeriwa enhlokweni kuva yitirhisiwa eka swiyimo leswi hlawuriweke laha nsinya wa tibial wu lavaka vuhandzuri lebyi pfulekeke ku fikelela kuhunguteka loku amukelekaka ka ku tshoveka.

Xifaniso 9. Ku tshoveka ka tibia leyi pfulekeke hi ku tshoveka lokukulu na ku tsandzeka ka marhambu, ku khomiwa ka cortical yin’we hi xisirhelelo lexitsongo emakumu lama tshovekeke ya ku tshoveka endzhaku ko hungutiwa na ku susiwa ka xisirhelelo endzhaku ka ku khomiwa ka swipikiri endzeni ka medullary

Xikongomelo xa xipikiri lexi sivelaka iku hunguta medullary cavity eka ndzhawu ya metaphyseal. Swipikiri leswi sivelaka swivekiwa endzeni ka xiphemu xo koma xa articular nale ka tlhelo ra concave ra deformity loko kungase vekiwa swipikiri swa intramedullary. Xikombiso, ku onhaka loku tolovelekeke ka ku tshoveka ka xiphemu xa vunharhu xa le kusuhi xa tibia ku tiveka hi valgus na forward angulation. Ku lulamisa ku onhaka ka valgus, xikurufu xo pfala xinga vekiwa eka xiphemu xale tlhelo xa xiphemu xa proximal fracture (i.e., tlhelo ra concave ra deformity) eka tlhelo ra anteroposterior. Xipikiri xa intramedullary xi kongomisiwa kusuka eka tlhelo ra le xikarhi, xisweswo xi sivela valgus. Hilaha ku fanaka, angulation deformity yinga hluriwa hiku veka locking screw medial kuya eka lateral kuya eka xiphemu xale ndzhaku xa proximal block (i.e., tlhelo ra concave ra deformity) (Xifaniso 10).

Xifaniso 10. assisted reset ya tibial fracture hi ku vekiwa ka swipikiri leswi pfalaka

-Ku andzisiwa ka medullary

Endzhaku ko hetisa ku vekiwa nakambe ka fracture, medullary reaming ya hlawuriwa ku lulamisela marhambu kuva ya nghenisiwa intramedullary nail. Guidewire leyinga na ball-ended yi nghenisiwa eka tibial marrow cavity nale ka ndzhawu leyi fracture yi tshovekeke, naswona reaming drill yi hundziseriwa ehenhla ka ball-ended guidewire. Ndzhawu ya ball-ended guidewire yi tiyisisiwile ehansi ka C-arm fluoroscopy kuva yiri eka levele ya ankle joint, naswona guidewire ayi kongomisiwile kahle eka mavonelo ya anteroposterior na lateral (Xifaniso 11).

Xifaniso xa 11. xi kombisa xiyimo xa guidewire eka medullary cavity eka C-arm fluoroscopy eka swiyimo swa le mahlweni na swa le tlhelo

Mhaka ya expanded versus non-expanded medulla yi vile na njhekanjhekisano. Hi tshemba leswaku madokodela yo tala ya vuhandzuri eAmerika N’walungu ma tsakela ku pfaleriwa ka tibia hi ku andlariwa ka medullary intramedullary ku tlula loku nga andlariwiki. Hambiswiritano, ku belela ka intramedullary loku andlariweke na loku nga andlariwangiki ku nga tirhisiwa tanihi tindlela leti amukelekaka ta ntolovelo, naswona vuyelo lebyinene byi nga kumiwa hi tindlela leti hatimbirhi.

-Ku vekiwa ka swikwirikiri swo pfala

Ku tirhisiwa ka swikwirikiri leswi hlanganisaka eka ku tshoveka ka nsinya wa tibial swi kongomisiwile ku sivela ku koma na ku rhendzeleka hi ndlela yo biha, ku andlala swikombiso swa intramedullary nailing ya tibia eka ku tshoveka ka nsinya wa tibial wa le kusuhi swinene na le kule loku katsaka metaphysis. Eka ku tshoveka loku katsaka ndzhawu ya metaphyseal, swikwirikiri leswi hlanganisaka swive swa nkoka swinene eka ku hlayisa ku ringanana ka axial.

Ti screw tinharhu ta proximal interlocking ti antswise swinene ku tiya, naswona ti angle-stabilized interlocking screws tinga nyika ku tshamiseka lokukulu kutlula ti interlocking screws ta ntolovelo, leswinga pfumelelaka ku tiya ka xivumbeko lexi fanaka ku kumiwa hi nhlayo yitsongo ya ti interlocking screws. Data ya tliliniki eka nhlayo na xivumbeko xa swikwirikiri leswi hlanganisaka leswi lavekaka eka ku khomiwa ka le ndzeni ka tibia swa ha ri switsongo.

Ku vekiwa ka ti proximal interlocking screws switala ku endliwa hiku tirhisa scope leyi khomanisiweke na intramedullary nail spike. Ti screws ta distal interlocking ti nghenisiwa hi voko hiku ntshunxeka ehansi ka nkongomiso wa fluoroscopic. Ku tirhisiwa ka sisiteme ya nkongomiso leyi pfuniwaka hi khompyuta ya electromagnetic swa hlohleteriwa eka ku nghenisiwa ka swikwirikiri swa distal tibial interlocking (Xifaniso 12). Endlelo leri ri pfumelela ku nghenisiwa ka swikwirikiri leswi hlanganisiweke swa le kule leswi nga riki na miseve naswona swi kombisiwile tanihi ndlela leyi kotekaka ni leyi kongomeke.

Xifaniso 12.AB Ku pfala swikwirikiri hi ku tirhisa C-arm perspective; Swikwirikiri swo pfala CD hi ku tirhisa ku pfala loku pfuniwaka hi khompyuta hi gezi

Ku vekiwa ka swikwirikiri leswi hlanganisaka swa le kusuhi na le kule i endlelo ra vuhandzuri leri hlayisekeke naswona swikwirikiri leswi hlanganisaka swi fanele ku nghenisiwa hi ndlela leyi kongomeke na leyi nga na xinghana na tinyama to olova.

Tidyondzo ta anatomic ti kombisile leswaku ka ha ri na khombo ra peroneal nerve palsy loko ku vekiwa ti proximal medial to lateral oblique interlocking screws. Ku hunguta khombo leri, madokodela ya vuhandzuri yafanele ku ehleketa ku bora swikwirikiri ehansi ka nkongomiso wa C-arm, na angle ya fluoroscopic ya C-arm perpendicular eka plane ya drill bit. Ku nghena ka drill eka cortex ya distal tibia swinga tika ku swivona hi tactile feedback, naswona kuva kusuhi na nhloko ya fibular swinga fihla ku vonakala ka tactile naswona swinyika dokodela wa vuhandzuri mavonelo ya leswaku u 'eka marhambu' kasi entiyisweni nhloko ya fibular yi nghenisiwile. Ku leha ka screw kungari ntsena hi graduated drill kambe na hi mimpimo leyi faneleke ya depth gauge. Ku pima kwihi na kwihi ka ku leha ka drill kumbe screw loku tlulaka 60 mm kufanele ku tlakusa ku kanakana ka posterolateral protrusion, leswinga vekaka common peroneal nerve eka khombo ro vaviseka.

Ti screws ta le kule leti hlanganisaka ta le mahlweni na ta le ndzhaku ti vekiwa hi ku tekela enhlokweni nsirhelelo wa anterolateral neurovascular bundle, tibialis anterior tendon, na extensor digitorum longus. Hambileswi ku vekiwa ka swikwirikiri hi ku tirhisa nhlonge hi ntolovelo swi hlayisekeke, madokodela ya vuhandzuri ma fanele ma tiva makhombo lama nga eka swivumbeko swa tinyama to olova leswi rhendzeleke. Eka ti tibial stem fractures totala, ti proximal na ti distal interlocking screws timbirhi tinyika kutshamiseka loku ringaneleke. Ku tshoveka ka tibial ya le kusuhi na le kule swi nga vuyeriwa hi ku vekiwa ka swikwirikiri swo engetela leswi hlanganisaka eka tipulani to hambana ku engetela ku tiya ka xivumbeko lexi (Xifaniso 13).

Xifaniso 13. Ku tshoveka ko tala ka tibia, loku tshunguriweke hi ku beleriwa ka intramedullary hi swikwirikiri swimbirhi swa le kule na swinharhu swa le kusuhi, na x-rheyi leyi landzelaka leyi ringanyetaka ku hola ka ku tshoveka.

-Ku Pfuxetiwa ka Fibular

Tidizayini ta manguva lawa ta swipikiri swa intramedullary leswingana ti distal interlocking screws ti ndlandlamuxe swikombiso swa intramedullary nailing ya tibia ku katsa na proximal na distal fractures leyi katsaka ndzhawu ya metaphyseal.

Ti configurations to hambana ta distal interlocking screw titirhisiwile eka ndzavisiso (2 screws kusuka eka medial kuya eka lateral ku hambana na 2 screws leti vekiweke perpendicular eka yin’wana na yin’wana na ntsengo wa 3 distal interlocking screws ku hambana na 1 distal interlocking screw ntsena). Eka vavabyi lava endliweke fibular fixation na tibial intramedullary nail fixation, mpimo wa ku lahlekeriwa hi reset a wu ri ehansi swinene. Nhlayo ya 13 % wa vavabyi lava nga na ku khomiwa ka swipikiri swa le ndzeni ka medullary handle ka fibular fixation va kombisile ku lahlekeriwa endzhaku ka vuhandzuri ka reset, loko ku pimanisiwa na 4 % wa vavabyi lava nga na tibial nail fixation handle ka fibular fixation.

Eka nkambisiso wun’wana lowu pimanisaka ku tirha kahle ka ku khomiwa ka swipikiri swa tibial intramedullary ku hambana na ku khomiwa ka fibular na ku khomiwa ka swipikiri swa tibial intramedullary ku hambana na ku pfumaleka ka ku khomiwa ka fibular, vavabyi lava tshunguriweke hi ku khomiwa ka fibular hi ku hlanganisiwa na ku hlanganisiwa ka tibial va kombisile ku antswisiwa eka ku ringanana ka rotational na inversion/eversion.

Hi gimeta hi leswaku adjunctive fibular fixation yi fikelela no hlayisa ku hunguteka ka tibial fracture eka distal one-third tibia fractures leyi endliwaka intramedullary nail fixation. Hambiswiritano, xiphiqo xa swiphiqo swa swilondza leswi humaka eka ku tsemiwa loku engetelekeke endhawini ya tinyama leti vavisekeke xa ha ri kona. Hikwalaho hi ringanyeta vuxiyaxiya eka ku tirhisiwa ka assisted fibular fixation.

03. Vuyelo bya kona

Intramedullary nailing fixation ya tibial stem fractures yinga humesa mbuyelo wa kahle. Tihakelo ta ku hola ka intramedullary nailing ya tibia ti vikiwile eka tidyondzo to hambana. Hiku tirhisiwa ka switirhisiwa swa manguva lawa leswi nghenisiweke na tindlela leti faneleke ta vuhandzuri, nhlayo ya ku hola yi languteriwile ku tlula 90 %. Mpimo wa ku hola ka ku tshoveka ka nsinya wa tibial lowu tsandzekeke ku hola endzhaku ka ku khomiwa ka swipikiri endzeni ka medullary wu antswisiwile swinene endzhaku ka ku khomiwa ka le ndzeni hi xipikiri xa vumbirhi lexi andlariweke xa le ndzeni ka medullary.

Ku kamberiwa ka mbuyelo eka lembe rin’we endzhaku ka vuhandzuri ku kombisile leswaku ku fika eka 44 % wa vavabyi va ye emahlweni va va na swipimelo swa ntirho eka makumu ya le hansi lama vavisekeke, naswona ku fika eka 47 % va ye emahlweni va vika vulema lebyi fambelanaka na ntirho eka lembe rin’we endzhaku ka vuhandzuri. Dyondzo yi ringanyeta leswaku vavabyi lava tshunguriwaka hi ku beleriwa ka tibia hi ku tirhisa intramedullary va ya emahlweni va va na swipimelo leswikulu swa ntirho eka nkarhi wo leha. Madokodela ya vuhandzuri ma fanele ma tiva timhaka leti naswona ma tsundzuxa vavabyi hi ku ya hi sweswo!

四. Swiphiqo swa le ndzhaku ka vuhandzuri

01. Ku vava ka le mahlweni ka patellar

Ku vava ka anterior patellofemoral i xiphiqo lexi tolovelekeke endzhaku ka intramedullary nail fixation ya tibial stem fractures. Mindzavisiso yi kombisile leswaku kwalomu ka 47 % wa vavabyi endzhaku ka intramedullary nailing va nga ha va na ku vava ka prepatellar, etiology ya kona yi nga twisiseki hi ku hetiseka. Swilo leswi nga vaka na nkucetelo swi nga katsa ku vaviseka loku chavisaka na ka swa vutshunguri eka swivumbeko swa le ndzeni ka swirho, ku vaviseka ka rhavi ra infrapatellar ra saphenous nerve, ku tsana ka misiha ya marhaku ya vumbirhi eka ku tshikileriwa ka ti-neuromuscular reflexes leti fambelanaka na ku vava, fibrosis ya fat pad leyi yisaka eka impingement, reactive patellar tendonitis, bending strain kusuka eka intramedullary ku belela ehenhla ka xiphemu xa le kusuhi xa tibia, na ku huma ka makumu ya le kusuhi ya xipikiri.

Loko ku dyondziwa etiology ya ku vava ka prepatellar endzhaku ka intramedullary nailing, endlelo ra transpatellar tendon ri pimanisiwile na endlelo ra parapatellar. Endlelo ra transpatellar tendon ri nga ha fambelanisiwa na ku va kona ka le henhla ka ku vava ka matsolo endzhaku ka vuhandzuri. Hambiswiritano, datha ya tliliniki leyi nga hlawuriwa hi ku landzelelana ya nkarhi lowu taka a yi kombisanga ku hambana lokukulu exikarhi ka endlelo ra transpatellar tendon na endlelo ra parapatellar.

Ku tirha kahle ka ku susiwa hi ku hlawula ka ku khomiwa ka le ndzeni ku lulamisa ku vava ka prepatellar endzhaku ka tibial intramedullary nailing a swi tiyiseki. Hi ringanyeta leswaku ku susiwa ka xipikiri xa intramedullary tibial ku tekeriwa enhlokweni loko ku nga tiviwa etiology ya michini, ku fana na ku huma ka xipikiri kumbe xikurufu xo hlanganisa lexi humelaka ehandle. Hambiswiritano, ku vuyeriwa ka ku susiwa ka swipikiri hi tibial intramedullary eka vavabyi lava nga ni swikombiso swa ha kanakana.

Malunghana na ku vava ka prepatellar endzhaku ka vuhandzuri, xivangelo xa ku vava a xi nga kombisiwi kahle eka dyondzo yo sungula ya tliliniki ya intramedullary nail fixation ya tibial nail eka patella eka xiyimo xa semi-extended. Hikwalaho, tidyondzo letikulu ta tliliniki leti nga na ku landzelerisa ka nkarhi wo leha ta laveka ku tiyisisa mbuyelo wa ku khomiwa ka swipikiri swa intramedullary eka endlelo ra suprapatellar eka ku vava ka prepatellar endzhaku ka vuhandzuri.

02.Ku nga ringani kahle endzhaku ka vuhandzuri

Post-traumatic osteoarthritis yi tshama yiri xiphiqo lexikulu endzhaku ka vutshunguri bya tibial stem fractures hi intramedullary nailing. Tidyondzo ta biomechanical ti kombisile leswaku tibial malalignment yinga endla leswaku kuva na ku cinca lokukulu eka ntshikelelo wa contact eka mahlangano ya ankle na matsolo lawa yanga ekusuhi.

Tidyondzo ta tliliniki leti kambelaka mimbuyelo ya nkarhi wo leha ya tliliniki na ya swifaniso endzhaku ka ku tshoveka ka nsinya wa tibial ti nyikile datha leyi kanetanaka eka switandzhaku swa tibial malalignment, ku nga ri na mahetelelo lama nga erivaleni ku fikela sweswi.

Swiviko swa ku nga ringani endzhaku ka vuhandzuri endzhaku ka ku beleriwa ka tibia hi intramedullary swi tshama swi ri switsongo, laha ku vikiweke nhlayo yitsongo ya timhangu. Ku cinca-cinca loku nga riki kahle endzhaku ka vuhandzuri ku tshama ku ri xiphiqo lexi tolovelekeke eka ku belela ka tibial intramedullary, naswona ku kamberiwa ka ku rhendzeleka ka tibial hi ku tirhisa vuhandzuri ku tshama ku ri ntlhontlho. Ku fikela sweswi, ku hava ku kamberiwa ka tliliniki kumbe ndlela ya swifaniso leyi simekiweke tanihi mpimanyeto wa nsuku wa ku kumisisa ku rhendzeleka ka tibia hi le ndzeni ka vuhandzuri.Ku kamberiwa ka xikambelo xa CT ku kombisile leswaku mpimo wa malrotation endzhaku ka ku beleriwa ka tibia hi intramedullary wu nga ha va ehenhla ku fika eka 19 % ku ya eka 41 %. Ngopfu ngopfu, ku onhaka ka ku rhendzeleka ka le handle swi vonaka swi tolovelekile ku tlula ku onhaka ka ku rhendzeleka ka le ndzeni. Ku kamberiwa ka tliliniki ku kambela ku cinca-cinca loku nga riki kahle endzhaku ka vuhandzuri ku vikiwile ku va ku nga ri ntiyiso naswona ku kombisile ku yelana ka le hansi na ku kamberiwa ka CT.

Hi tshemba leswaku ku nga ringani ku tshama ku ri xiphiqo xa nkarhi wo leha eka ku tshoveka ka nsinya wa tibial loku tshunguriweke hi ku beleriwa ka tibia hi intramedullary. Hambi leswi ku nga na datha leyi kanetanaka mayelana na vuxaka exikarhi ka ku nga ringani na mimbuyelo ya tliliniki na ya swifaniso, hi ringanyeta leswaku madokodela ya vuhandzuri ya fanele ku lwela ku fikelela ku ringanana ka anatomic ka ku tshoveka leswaku ya ta lawula ku cinca-cinca loku na ku kuma mbuyelo lowunene.

五. Mahetelelo

Static locking expanded medullary intramedullary nailing yitshama yiri vutshunguri bya ntolovelo eka ku tshoveka ka nsinya wa tibial lowu rhurheriweke. Ndhawu leyinene yo nghena yi tshama yi ri xiphemu xa nkoka xa endlelo ra vuhandzuri. Endlelo ra suprapatellar eka xiyimo xa semi-extended ri tekiwa tani hi endlelo leri hlayisekeke no tirha kahle, naswona tidyondzo ta nkarhi lowu taka ti lava ku ya emahlweni ti kambela makhombo na mimpfuno ya endlelo leri. Dokodela wa vuhandzuri loyi a nga ta va a ri karhi a tolovelana ni tindlela ta manguva lawa to tlhela a veka ndhawu. Loko ku ringanisiwa ka anatomic fracture kunga fikeleriwa hiku tirhisa maendlelo yo pfala, tindlela to hunguta incisional tifanele ku tekeriwa enhlokweni. Tihakelo ta kahle ta ku hola kutlula 90 % tinga fikeleriwa hiku andlariwa na lokunga andlariwaka ka intramedullary nailing. Ku nga khathariseki mpimo lowunene wa ku hola, vavabyi va ha ri ni swiphiqo swa nkarhi wo leha swa ntirho. Ngopfu ngopfu, ku vava ka prepatellar ku tshama ku ri xivilelo lexi tolovelekeke endzhaku ka tibial intramedullary nailing. Ku engetela kwalaho, malrotation endzhaku ka internal tibial fixation ya ha ri xiphiqo lexi tolovelekeke.

Swikombo

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01;15:207-209. doi: 10.1097/00005131-200103000-00010 .na swin'wana na swin'wana......