I-Tibial Intramedullary Nail Fixation Technique

Ukulungiswa kwesikhonkwane se-Intramedullary kuhlala kunyango olukhethiweyo lokungazinzi kunye nokufuduka kwe-tibial stem fractures kubantu abadala. Injongo yonyango lotyando kukubuyisela ubude, ukulungelelaniswa kunye nokujikeleza kwe-tibia kunye nokufezekisa ukuphulukiswa kokuphuka. Iingenelo zokubethelwa kwe-intramedullary yintlupheko encinci yotyando kunye nokugcinwa okufanelekileyo kokunikezelwa kwegazi kwi-fracture. Ukongezelela, ukubethelwa kwe-intramedullary ye-tibia kunika uzinzo olufanelekileyo lwe-biomechanical fracture kwaye lusebenza njengesixhobo sokwabelana ngomthwalo esivumela ukuhlanganiswa kwangaphambili emva kokusebenza. Ukuqhubela phambili kwi-intramedullary nail design kunye nobuchule bokunciphisa baye bandisa izibonakaliso zokulungiswa kwesikhonkwane se-intramedullary ukubandakanya i-proximal tibia kunye ne-fractures ephakathi kwesithathu.

Kuze kube namhlanje, ukucutha okuvaliweyo kwe-intramedullary nail fixation ye-tibial fractures kuye kwaba yinkqubo eqhelekileyo yokuhlinzwa kwamathambo e-trauma. Ngaphandle kokuthandwa kwe-intramedullary nail fixation ye-tibial stem fractures efudukayo, ihlala ingumngeni kwaye ineengxaki ezininzi ezinokubakho. Ubuchule botyando buyaqhubeka nokuguquka. Injongo yale nqaku kukuchaza iikhonsepthi zangoku kwi-intramedullary nail fixation of tibial stem fractures kunye nokushwankathela ukuqhubela phambili kwangoku kwintsimi.

一. Uvavanyo lokuqala kunye nokuhlolwa

Kwizigulane ezincinci, i-tibial stem fractures idla ngokuba ngumphumo wokulimala kwamandla aphezulu, kwaye izigulane kufuneka zihlolwe ngenxa yokuxhatshazwa okuhambelanayo ngokwemigaqo ye-Advanced Trauma Life Support (ATLS). Vavanya ulusu olujikelezileyo kunye nokulimala kwezicubu ezithambileyo ezinje ngamadyungudyungu aqhekekayo, ukuqhawuka kwesikhumba, ukutshisa, i-ecchymosis, okanye ukuphakama kwesikhumba; ukucacisa ukuba i-fracture ivulekile, kwaye ukuba kunjalo phatha nge-tetanus kunye ne-antibiotics; kwaye wenze uviwo olucokisekileyo lwe-neurovascular kwaye ubhale oku ngasentla. Vavanya ukwenzeka kwe-osteofascial compartment syndrome kwaye wenze uluhlu lweemviwo zeklinikhi kwezi zigulana.

Uphando olutshanje luye lwabonisa ukuba iziganeko ze-osteofascial compartment syndrome emva kwe-tibial tuberosity fractures ingaba phezulu njenge-11.5%. Ngokukodwa, amaqela amancinci ezigulane kunokwenzeka ukuba aphuhlise i-osteofascial compartment syndrome. Ukuxilongwa kwe-osteofascial compartment syndrome kufuneka kusekelwe kwiziphumo zeklinikhi, kubandakanywa intlungu enzima, utshintsho lwe-neurovascular, ukuvuvukala kwe-myofascial compartment, kunye nokwanda kweentlungu ezivela ekwandisweni kweenzwane. Ke ngoko, i-osteofascial compartment syndrome ihlala ixilongo lweklinikhi kwaye amaxwebhu apheleleyo ovavanyo lweklinikhi abalulekile. Uxinzelelo ngaphakathi kwendawo ye-myofascial inokulinganiswa ngokusetyenziswa kwenaliti yoxinzelelo (Umfanekiso 1) njengendlela yokuhlola eyongezelelweyo kwiimviwo ezikhethekileyo.

Umzobo 1. Umlinganiselo woxinzelelo kwi-septum ye-interosseous ngokusebenzisa inaliti yoxinzelelo.

Ukufumana idatha ethembekileyo, uxinzelelo lwe-intrafascial kufuneka lulinganiswe kwiindawo ezine ze-myofascial kunye neendawo ezahlukeneyo ngaphakathi kwendawo nganye ye-myofascial. Uphononongo kuncwadi lubonisa ukuba ukuhluka koxinzelelo olungaphantsi kwe-30 mmHg (uxinzelelo lwe-diastolic lukhupha uxinzelelo lwe-fascial compartment) lubonisa i-fascial compartment syndrome. Uxinzelelo lwe-diastolic luhlala luyancipha ngexesha lotyando, kwaye uxinzelelo lwe-diastolic lwangaphambi kokuhlinzwa kufuneka luthathelwe ingqalelo xa kubalwa ukuhlukana koxinzelelo.

Uphononongo lwakutsha nje lubonise ukuba ukujongwa koxinzelelo lwe-intrafascial sisixhobo esinokuba luncedo ekuxilongweni kwe-acute fascial compartment syndrome, enobuntununtunu be-94% kunye ne-98%. Nangona kunjalo, ngenxa yemiphumo enokuba yingozi ye-compartment syndrome, ukuxilongwa kwe-compartment syndrome kufuneka kusekelwe kwiziphumo zeklinikhi, kwaye imilinganiselo yoxinzelelo lwe-compartment edibeneyo kufuneka isetyenziswe kwiimeko ezikhethekileyo, njengaxa isigulane senzakala okanye xa amanqaku edatha yekliniki engacacanga.

Ukuphonononga ukuvavanya kufuneka kubandakanye i-orthopantomograms eqhelekileyo kunye neembono zecala le-tibia eyonzakeleyo kunye ne-radiographs yedolo elisondeleyo kunye namalungu e-ankle, aphinde ahlolwe kusetyenziswa i-computed tomography (CT). Ngokufanayo, i-CT scan ye-ankle inokuba yimfuneko ukujonga imigca yokuphuka eya kwi-plateau ye-tibial kunye nokulimala kwe-ankle okuhambelanayo.

二. Imigibe yeklinikhi

Ipesenteji ephezulu yokuphuka kwesithathu esisezantsi esiphakathi kwe-tibia kunye ne-ankle fractures ziye zabikwa. Ukusebenzisa i-CT scans eziqhelekileyo, i-43% yokuphuka kwe-middle and low third ye-tibia yayihamba kunye ne-ankle fractures, ininzi efuna unyango lotyando. Olona hlobo luqhelekileyo lokuphuka lwaluyi-spiral fracture ye-spiral ephakathi kwesithathu esisezantsi se-distal tibia ehambelana ne-ankle encinci okanye engabonakaliyo emva kwe-ankle fracture (Umfanekiso 2). Ngenxa yokufuduka okuncinci kwe-ankle fracture ehambelanayo, kuphela i-45% yokulimala inokubonwa kwi-radiographs ye-ankle. Ngoko ke, i-CT scans yesiqhelo ye-ankle kufuneka igxininiswe kakhulu xa i-fracture ye-tibia ephantsi ikhona (umzobo 3).

Umzobo 2.AF Ukuqhekeka kwe-Spiral kwesithathu esisezantsi esiphakathi kwe-tibia yasekunene (A, B) I-radiographs yangaphambi kokusebenza kwe-ankle ibonisa eqhelekileyo (C). I-Intraoperative C-arm fluoroscopy ibonisa ukuphuka okungahambi kakuhle kwe-ankle yangasemva (D) I-radiographs yasemva kokuhlinzwa emva kokulungiswa kotyando (EF) ibonisa ukuphulukiswa kakuhle kwe-tibial kunye ne-ankle fractures.

Umzobo 3. I-AF Spiral fracture ye-middle and low third of the left tibia (AB) preoperative radiographs; (CD) ii-CT scans zangaphambili ezibonisa i-nondisplaced posterior malleolar fracture; (EF) ebonisa ukuphiliswa okungaqhelekanga kwe-tibia kunye ne-malleolar fracture

三. Iindlela zotyando

01. Indawo yokuNgena kweNaliti yeTibial

Ukuseka indawo yokungena echanekileyo idlala indima ebalulekileyo kwaye izifundo ezininzi kwiincwadi zinike ulwazi olubalulekileyo kwindawo ye-anatomical yendawo yokungena efanelekileyo yokubethelwa kwe-intramedullary ye-tibial fractures. Ezi zifundo zibonise ukuba i-pinning point efanelekileyo ibekwe kumda wangaphambili we-plateau ye-tibial kunye ne-medial nje kwi-lateral tibial spur. Indawo yokhuseleko enobubanzi be-22.9 mm ± 8.9 mm, engabangeli umonakalo kwizakhiwo ezidibeneyo ezikufutshane, nayo yaxelwa. Ngokwesiko, indawo yokuqala yokulungiswa kwe-intramedullary nail fractures ye-tibial stem fractures iye yasekwa ngendlela ye-infrapatellar, mhlawumbi ngokuhlukana kwe-tendon ye-patellar (indlela ye-transpatellar) okanye ngokukhupha inxalenye ye-patellar tendon stop (indlela ye-paratendinous).

Ukwandiswa kwe-Semi-extension intramedullary nailing kuye kwatsala ingqalelo enkulu kwiincwadi zamathambo zamva nje, kwaye i-Tornetta kunye ne-Collins bacebisa ukuba kusetyenziswe indlela ye-parapatellar ye-medial yokulungiswa kwangaphakathi kwesikhonkwane kwi-semi-extension position ukuphepha ukukhutshwa kwe-apex ye-intramedullary isikhonkwane kwi-anterior tibial cortex kwi-nail ye-nail intramedullal3. indawo yolwandiso lwesiqingatha nayo iyacetyiswa. Ukusetyenziswa kwendlela ye-suprapatellar ye-tibial intramedullary nailing kunye nokufakwa kwe-intramedullary nail ngokusebenzisa i-patellofemoral joint kwi-semi-extended position.

Inkqubo yenziwa ngedolo eliguquguqukayo malunga ne-15-20 degrees, kwaye i-longitudinal incision malunga ne-3 centimeters yenziwa malunga nobubanzi beminwe emibini ngaphezu kwepatella. I-tendon ye-quadriceps ihlulwe ngendlela ye-longitudinal kunye ne-blunt dissection yenziwa kwi-patellofemoral joint. I-socket edibeneyo ifakwe kwi-patellofemoral joint ukudala indawo yokungena ekudibaneni kwe-cortex yangaphambili ye-tibial kunye ne-articular surface (Umfanekiso 4).

Umzobo 4. ab iifoto ze-Intraoperative (a) ukwahlula i-tendon ye-quadriceps kunye nokufaka i-trocar ngokusebenzisa i-patellofemoral joint to the tibial entry point; (b) imbonakalo esecaleni yangaphakathi kwendawo yokungena

I-drill bit 3.2 mm isetyenziselwa ukumisela indawo yenaliti yokuqala phantsi kwesikhokelo se-C-arm. I-socket ene-perforated inikezelwa ukulungisa kakuhle indawo yokungena kunye nokuphuma. Iinkqubo zotyando eziseleyo ezibandakanya ukubuyisela kwakhona kunye nokufakwa kwe-tibial nail zenziwa nge-socket.

I-ADVANTITS ENGASEKHO: I-semi-extended leg position inokunceda ekubuyiseleni i-fracture, ngakumbi kwiifractures kunye ne-third proximal ye-tibia kunye ne-angled phambili. , Isikhundla esongeziweyo se-semi-extended singaphelisa ukuxhatshazwa kwi-quadriceps muscle kunye nokunceda ekubuyiseleni i-fracture. , Indlela ye-semi-extended position ye-suprapatellar nayo inokuba yinye indlela yendabuko ye-infrapatellar (Umfanekiso 5).

Umzobo 5. Ifoto ye-Intraoperative ebonisa ukulimala kwezicubu ezithambileyo kwingingqi ye-infrapatellar njengesalathisi sendlela ye-suprapatellar kwindawo eyongeziweyo.

Uphononongo lubonise ukuba indlela ye-suprapatellar kwi-tibial intramedullary nailing in the semi-extended position yindlela ekhuselekileyo nesebenzayo yotyando. Iimvavanyo zeklinikhi zexesha elizayo ziyafuneka ukuphanda ngakumbi iingenelo kunye nokungonakali kwendlela ye-suprapatellar yokubethelwa kwe-intramedullary kunye nokuvavanya iziphumo zexesha elide ezinxulumene nobu buchule.

02. Setha kwakhona iteknoloji

Ukubekwa kwe-tibial intramedullary nail yodwa akuphumeleli ekunciphiseni ukuphuka okwaneleyo; ukunciphisa ukuphuka okufanelekileyo kufuneka kugcinwe kuyo yonke inkqubo yokuvuselela kunye nokubekwa kwe-intramedullary nail. Ukusetyenziswa kwe-manual traction kuphela akunakusoloko kufezekisa ukunciphisa i-anatomic yokwaphuka ngokwayo. Eli nqaku liza kuchaza iindlela ezahlukeneyo ezivaliweyo, ezihlaselayo ezincinci, kunye nezivulelekileyo zokunciphisa.

-Kuvaliwe iingcebiso zobugcisa

Ukuvalwa kokunciphisa ukunyanzeliswa kokunciphisa kunokufezekiswa ngesixhobo sokunciphisa njenge-F-fracture reducer, i-F-shaped radiographically transmissible reduction device elungisa i-inversion / i-angles ye-exversion kunye ne-medial / lateral translation (Umfanekiso 6).

Umzobo 6. Isinciphisi sokuqhekeka okumilise ngo-F esikhankanywe kutyando

Nangona kunjalo, isixhobo sinokubeka uxinzelelo olukhulu kwizicubu ezithambileyo, kwaye ukusetyenziswa ixesha elide kwesi sixhobo sokusetha kwakhona kufuneka kugwenywe. I-forceps yokunciphisa inokuthi ibekwe nge-percutaneously, njengakwimeko ye-spiral kunye ne-oblique fractures. Ezi zixhobo zinokusetyenziswa ngendlela enobubele kwizicubu ezithambileyo ngokusebenzisa ama-incision amancinci (Umfanekiso 7).

Umzobo 7. I-Percutaneous clamping ukusetha kwakhona i-tibial fracture

Uhlobo lwe-clamp kunye nendawo ye-incision yokuhlinzwa kufuneka ikhethwe ngokusekelwe kwisicwangciso sokunciphisa umonakalo wexesha elide kwizicubu ezithambileyo ukusuka ekubekweni kwe-clamp (Umfanekiso 8).

Umzobo 8. I-forceps ekhonjiweyo yokubuyisela ukusetha kwakhona i-tibial fracture

I-retractors nayo enye yezixhobo eziqhelekileyo zokusetha kwakhona ezisetyenziselwa ukubuyisela ubude kwi-tibia. Ngokuqhelekileyo zibekwe kwi-medially kwaye zikude nendawo apho i-intramedullary nail kufuneka ibekwe khona. Izikhonkwane zokutsalwa ezikufutshane zinokubekwa ukulinganisa indawo ye-screw yokuthintela, evumela ukucuthwa lula kwe-fracture xa isikhonkwane se-intramedullary singenile.

Kwezinye iimeko, iindlela zokucutha ezivaliweyo kunye nezincinci azanelanga ukufumana ukuncipha kwe-anatomic. Kwiimeko ezinjalo, iindlela zokunciphisa i-incisional kufuneka ziqwalaselwe ngolawulo olucokisekileyo lwezicubu ezithambileyo ezijikelezayo. Izinto ezinokuthi zibe khona zeendlela ezivulelekileyo zokunciphisa ziquka umonzakalo owongezelelweyo wotyando, onokunyusa umngcipheko wokosuleleka kwindawo yotyando. Ukongezelela, ukuchithwa okongeziweyo kwegazi kwindawo yokuphuka kunokunyusa umngcipheko we-postoperative fracture nonunion.

-Izakhono zobuGcisa zokusikwa kunye nokuBekwa ngokutsha

Iindlela zokunciphisa i-incisional zivumela ukuba kungekuphela nje i-forceps yokunciphisa utyando ebekwe kwindawo efanelekileyo, kodwa kunye nokusetyenziswa kwe-splints encinci okanye encinci kwindawo yokuphuka ukugcina ukuncitshiswa kwe-fracture ngexesha leenkqubo zokubethelwa kwe-intramedullary.

Amacwecwe akhuselwe kwi-proximal kunye ne-distal fracture fragments usebenzisa izikrufu ze-monocortical. I-splint igcinwe kuyo yonke inkqubo yokuvuselela kunye nokubekwa kwesikhonkwane se-intramedullary kwi-tibia. Emva kokubekwa kwesikhonkwane se-intramedullary, ipleyiti yasuswa okanye ishiywe kwindawo yokuphucula ukuzinza kwesakhiwo esisisigxina (Umfanekiso 9). Ngokushiya ipleyiti endaweni, isikrufu secortical enye kufuneka sitshintshwe ngesikrufu secortical ephindwe kabini. Kufuneka kuthathelwe ingqalelo ukusetyenziswa kwiimeko ezikhethiweyo apho i-tibial stem idinga utyando oluvulekileyo ukuze kuphunyezwe ukunciphisa ukwaphuka okwamkelekileyo.

Umzobo 9. Ukuphuka kwe-tibia evulekileyo kunye nokuhamba okunzima kunye nokukhubazeka kwamathambo, ukulungiswa kwe-cortical eyodwa kunye ne-splint encinci ekupheleni kweqhekeza emva kokunciphisa kunye nokususwa kwe-splint emva kokulungiswa kwe-intramedullary nail.

Injongo yesikhonkwane sokuthintela kukunciphisa i-medullary cavity kwingingqi ye-metaphyseal. Izikhonkwane zokuthintela zifakwe ngaphakathi kweqhekeza elifutshane le-articular kunye necala le-concave lokukhubazeka ngaphambi kokubekwa kwe-intramedullary nail. Ngokomzekelo, ukukhubazeka okuqhelekileyo kokuqhekeka kwe-proximal yesithathu ye-tibia kubonakaliswe nge-valgus kunye ne-angulation phambili. Ukulungisa i-valgus deformity, i-screw yokuvala ingafakwa kwi-lateral ye-fragment fragment proximal fragment (oko kukuthi, i-concave side of deformity) kwindlela ye-anteroposterior. Isikhonkwane se-intramedullary sikhokelwa ukusuka kwicala eliphakathi, ngaloo ndlela sikhusela i-valgus. Ngokufanayo, i-angulation deformity inokoyiswa ngokubeka i-screw yokutshixa i-medial ukuya kwicala elingasemva kwi-block proximal block (okt, icala le-concave lokukhubazeka) (Umfanekiso we-10).

Umzobo 10. uncedise ukusetha kwakhona kwe-tibial fracture ngokubeka izikhonkwane zokuthintela

-Ukwandiswa okwethutyana

Emva kokugqiba i-fracture repositioning, i-medullary reaming ikhethiwe ukulungiselela ithambo lokufakwa kwe-intramedullary nail. I-ball-ended guidewire ifakwe kwi-tibial marrow cavity kunye nesayithi lokuphuka, kwaye i-reaming drill idluliswa phezu kwe-ball-ended guidewire. Isikhundla se-ball-ended guidewire saqinisekiswa phantsi kwe-C-arm fluoroscopy ukuba ibe kwinqanaba le-ankle joint, kwaye i-guidewire yayigxininiswe kakuhle kwiimbono zombini ze-anteroposterior kunye ne-lateral (Umfanekiso 11).

Umfanekiso we-11. ubonisa indawo ye-guidewire kwi-medullary cavity kwi-C-arm fluoroscopy kwindawo yangaphambili kunye neendawo ezisecaleni.

Umba wokwandiswa kuthelekiswa ne-medulla engandiswanga ibe yimpikiswano. Sikholelwa ukuba oogqirha abaninzi baseMntla Melika bakhetha ukubethelwa kwe-medullary intramedullary eyandisiweyo ye-tibia ukuba ingandi. Nangona kunjalo, zombini i-intramedullary nailing eyandisiweyo kunye ne-non-expaned ingasetyenziswa njengeendlela ezisemgangathweni ezamkelekileyo, kwaye iziphumo ezilungileyo zinokufumaneka ngeendlela zombini.

-Ukutshixa isikrufu sokubekwa

Ukusetyenziswa kwe-screws edibeneyo kwi-tibial stem fractures yenzelwe ukuthintela ukunciphisa kunye ne-malrotation, ukwandisa izibonakaliso zokubethelwa kwe-intramedullary ye-tibia ukuya kwi-proximal and distal stem fractures ebandakanya i-metaphysis. Kwiifractures ezibandakanya ummandla we-metaphyseal, i-screws edibeneyo yaba yinto ebaluleke kakhulu ekugcineni ukulungelelaniswa kwe-axial.

Izikrufu ezithathu ezidityanisiweyo ezisondeleleneyo ziphucule ngokuphawulekayo uzinzo, kunye nezikrufu ezibambeneyo ezizinzileyo zinokunika uzinzo olukhulu kunezikrufu eziqhelekileyo ezidityanisiweyo, ezinokuvumela ukuzinza okufanayo kwesakhiwo kufumaneke ngenani elincinane lezikrufu ezidityanisiweyo. Idatha yeklinikhi kwinani kunye nokucwangciswa kwezikrini ezidibeneyo ezifunekayo ukulungiswa kwangaphakathi kwe-tibia zihlala zilinganiselwe.

Ukubekwa kwezikrufu ezinxuseneyo ezisondeleleneyo ngokuqhelekileyo kwenziwa kusetyenziswa i-scope eqhotyoshelwe kwi-intramedullary nail spike. Izikrufu ezidityanisiweyo ezidityanisiweyo zifakwe simahla phantsi kwesikhokelo se-fluoroscopic. Ukusetyenziswa kwenkqubo yesikhokelo sombane we-electromagnetic encediswa yikhompyuter kuyacetyiswa ukuba kufakwe izikrufu ezidityanisiweyo ze-tibial (Umfanekiso we-12). Obu buchule buvumela ukufakwa ngaphandle kokusasazeka kwemitha kwezikrufu ezidityanisiweyo ezidityanisiweyo kwaye zibonakaliswe njengendlela enokwenzeka nechanekileyo.

Umzobo 12.AB Izikrufu zokutshixa ngembono ye-C-arm; I-CD yokutshixa izikrufu ngokutshixa nge-electromagnetic encediswa yikhompyuter

Ukubekwa kwezikrufu ezisondeleleneyo ezisondeleleneyo kunye ne-distal yinkqubo yotyando ekhuselekileyo kwaye izikrufu ezidityanisiweyo kufuneka zifakwe ngendlela echanekileyo nethambileyo enobuhlobo.

Izifundo ze-anatomic zibonise ukuba kusekho umngcipheko we-peroneal nerve palsy xa ubeka i-proximal medial ukuya kwi-lateral oblique interlocking screws. Ukunciphisa lo mngcipheko, oogqirha botyando kufuneka baqwalasele ukugrumba izikrufu phantsi kwesikhokelo se-C-arm, kunye ne-angle ye-fluoroscopic ye-C-arm perpendicular kwinqwelomoya ye-drill bit. Ukungena kwe-Drill kwi-cortex ye-distal tibia kunokuba nzima ukuyibona ngempendulo ye-tactile, kwaye ukusondela kwentloko ye-fibular kunokufihla i-tactile impression kwaye inike ugqirha ingcamango yokuba 'kwithambo' xa ngokwenene intloko ye-fibula ingene. Ubude bezikrikri abufanele bugqitywe kungekuphela nje ngoqeqesho oluthweswe izidanga kodwa nangobunzulu obufanelekileyo bemilinganiselo. Nayiphi na i-drill okanye ubude bokulinganisa ubude obungaphezulu kwe-60 mm kufuneka ikhulise ukukrokra kwe-posterolateral protrusion, enokuthi ibeke i-nerve ye-peroneal eqhelekileyo engozini yokulimala.

I-distal yangaphambili kunye ne-posterior interlocking screws ibekwe ingqalelo ekukhuselweni kwe-anterolateral neurovascular bundle, i-tibialis anterior tendon, kunye ne-extensor digitorum longus. Nangona i-percutaneous screw placement ihlala ikhuselekile, oogqirha botyando kufuneka baqaphele umngcipheko kwizakhiwo ezithambileyo ezijikelezileyo. Ubuninzi be-tibial stem fractures, i-screws ezimbini ezijikelezayo kunye ne-distal interlocking screws zibonelela ngokuzinza okwaneleyo. I-proximal and distal tibial fractures inokuzuza ngokubeka izikrini ezongezelelweyo ezidibeneyo kwiiplani ezahlukeneyo zokwandisa ukuzinza kwesi sakhiwo (Umfanekiso 13).

Umzobo 13. Iifractures ezininzi ze-tibia, ziphathwa nge-intramedullary nailing with two distal and three proximal interlocking screws, kunye ne-x-rays elandelayo ebonisa ukuphulukiswa kwe-fracture.

-Ukulungiswa kweFibular

Uyilo lwezikhonkwane ze-intramedullary zangoku kunye nezikrufu ezidityanisiweyo ezidibeneyo ziye zandisa izibonakaliso zokubethelwa kwe-intramedullary ye-tibia ukubandakanya i-proximal kunye ne-distal fractures ebandakanya ummandla we-metaphyseal.

I-distal interlocking screw configurations isetyenzisiwe kuphononongo (izikrufu ezi-2 ukusuka kwi-medial ukuya ngakwicala elichasene ne-2 screws ezibekwe kwi-perpendicular enye kwenye kunye ne-3 iyonke ye-distal interlocking screws ngokuchasene ne-1 distal interlocking screw kuphela). Kwizigulane eziye zafumana ukulungiswa kwe-fibular kunye ne-tibial intramedullary nail fixation, izinga lokubuyisela ukulahleka laliphantsi kakhulu. Iyonke i-13% yezigulane ezine-intramedullary nail fixation ngaphandle kokulungiswa kwe-fibular zibonise ukulahleka kwe-postoperative yokusetha kwakhona, xa kuthelekiswa ne-4% yezigulane ezine-tibial nail fixation ngaphandle kokulungiswa kwe-fibular.

Kwesinye isilingo esithelekisa ukusebenza kwe-tibial intramedullary nail fixation ngokubhekiselele kwi-fibular fixation kunye ne-tibial intramedullary nail fixation ngokuchasene nokulungiswa kwe-fibular, izigulane eziphathwe nge-fibular fixation ngokudibanisa ne-tibial nailing zibonise ukuphucula ukujikeleza kunye nokuguqulwa / ukulungelelaniswa kwe-eversion.

Siphetha ukuba ukulungiswa kwe-fibular edibeneyo kufezekisa kwaye kugcinwe ukucuthwa kwe-tibial fracture kwi-distal one-third tibia fractures ehamba nge-intramedullary nail fixation. Nangona kunjalo, ingxaki yeengxaki zenxeba ezivela kwiincision ezongezelelweyo kwindawo yezicubu ezithintekayo zihlala. Ngoko ke sincoma ukuba uqaphele ekusebenziseni ukulungiswa kwe-fibular encedisiweyo.

03. Iziphumo

Ukulungiswa kwe-Intramedullary nailing of tibial stem fractures kunokuvelisa iziphumo ezilungileyo. Amazinga okuphilisa i-intramedullary nailing of the tibia achazwe kwizifundo ezahlukeneyo. Ngokusetyenziswa kokufakelwa kwanamhlanje kunye neendlela ezifanelekileyo zotyando, amazinga okuphilisa kulindeleke ukuba adlule kwi-90%. Izinga lokuphulukisa i-tibial stem fractures engaphumelelanga ukuphilisa emva kokulungiswa kwe-intramedullary nail yaphuculwa ngokumangalisayo emva kokulungiswa kwangaphakathi kunye nesibini esandisiweyo se-intramedullary nail.

Uvavanyo lwesiphumo kunyaka omnye emva kokuhlinzwa lubonise ukuba ukuya kwi-44% yezigulane ziqhubekile zinemida yokusebenza kwindawo eyonzakeleyo ephantsi, kwaye ukuya kuthi ga kwi-47% yaqhubeka ichaza ukukhubazeka okunxulumene nomsebenzi kunyaka omnye emva kokuhlinzwa. Uphononongo lubonisa ukuba izigulane eziphathwe nge-intramedullary nailing of the tibia ziyaqhubeka zinemida yokusebenza ebalulekileyo kwixesha elide. Oogqirha botyando kufuneka baqaphele le miba kwaye bacebise izigulane ngokufanelekileyo!

四. Iingxaki zasemva kotyando

01. Intlungu yangaphambi kwepatellar

Intlungu ye-patellofemoral yangaphambili yingxaki eqhelekileyo emva kokulungiswa kwe-intramedullary nail ye-tibial stem fractures. Uphononongo lubonise ukuba malunga ne-47% yezigulane emva kokubethelwa kwe-intramedullary inokuphuhlisa intlungu ye-prepatellar, i-etiology engaqondwa ngokupheleleyo. Izinto ezinokuthi ziphembelele zingabandakanya ukwenzakala okubuhlungu kunye nonyango kwizakhiwo ze-intra-articular, ukulimala kwisebe le-infrapatellar ye-nerve ye-saphenous, ubuthathaka bemisipha yethanga emva kokunyanzeliswa kwe-reflexes ye-neuromuscular ehlobene nentlungu, i-fibrosis ye-fat pad ekhokelela ekungeneni, i-patellar tendonitis esebenzayo, ukugoba kwi-protellar tendonitis, ukugoba kwi-prostrate ye-naxia kunye ne-naxia. ukuvela kwesiphelo esisondeleyo sesikhonkwane.

Xa ufunda i-etiology yeentlungu ze-prepatellar emva kokubethelwa kwe-intramedullary, indlela ye-tendon transpatellar yafaniswa nendlela ye-parapatellar. Indlela ye-tendon ye-transpatellar inokudibaniswa nesiganeko esiphezulu sentlungu yamadolo emva kokuhlinzwa. Nangona kunjalo, idatha yeklinikhi elindelekileyo ayizange ibonise naluphi na umahluko omkhulu phakathi kwendlela ye-tendon transpatellar kunye ne-parapatellar approach.

Ukusebenza kokususwa okukhethiweyo kokulungiswa kwangaphakathi ukujongana neentlungu ze-prepatellar emva kwe-tibial intramedullary nailing akuqinisekanga. Sincoma ukuba ukususwa kwesikhonkwane se-intramedullary tibial kuthathelwe ingqalelo ukuba i-etiology yomatshini inokuchongwa, njenge-nail protrusion okanye i-screw edibeneyo edibeneyo. Nangona kunjalo, inzuzo yokususwa kwezipikili ze-tibial intramedullary kwizigulane ezineempawu zihlala zingathandabuzeki.

Ngokuphathelele intlungu ye-postoperative prepatellar, imbangela yentlungu ayinakubonakaliswa ngokucacileyo kwisifundo sokuqala seklinikhi ye-intramedullary nail fixation ye-tibial nail kwi-patella kwi-semi-extended position. Ngoko ke, izifundo ezinkulu zeklinikhi kunye nokulandelwa kwexesha elide ziyimfuneko ukuze kuqinisekiswe umphumo we-intramedullary nail fixation kwindlela ye-suprapatellar kwi-postoperative prepatellar pain.

02.Ulungelelwaniso lwasemva kokusebenza kakubi

I-post-traumatic osteoarthritis ihlala iyingxaki ebalulekileyo emva kokunyangwa kwe-tibial stem fractures kunye ne-intramedullary nailing. Izifundo ze-Biomechanical zibonise ukuba i-tibial malalignment ingabangela utshintsho oluphawulekayo kwiingcinezelo zoqhagamshelwano kwi-ankle esondeleyo kunye namadolo.

Izifundo zeklinikhi ezivavanya iziphumo zexesha elide zeklinikhi kunye ne-imaging emva kokuphuka kwe-tibial stem fracture ziye zanika idatha ephikisanayo malunga ne-sequelae ye-tibial malalignment, kungekho zigqibo ezicacileyo ukuza kuthi ga ngoku.

Iingxelo ze-postoperative malalignment emva kokubethelwa kwe-intramedullary ye-tibia zihlala zilinganiselwe, kunye nenani elincinci lamatyala abikiweyo. I-postoperative malrotation ihlala iyingxaki eqhelekileyo kwi-tibial intramedullary nailing, kunye nokuhlolwa kwe-intraoperative yokujikeleza kwe-tibial kuhlala kunzima. Ukuza kuthi ga ngoku, akukho luvavanyo lweklinikhi okanye indlela yokucinga iye yasekwa njengomgangatho wegolide wokumiselwa kwe-intraoperative ye-tibial rotation.Uvavanyo lokuhlolwa kwe-CT luye lwabonisa ukuba izinga lokungahambi kakuhle emva kokubethelwa kwe-intramedullary ye-tibia ingaba phezulu kwi-19% ukuya kwi-41%. Ngokukodwa, ukukhubazeka kokujikeleza kwangaphandle kubonakala kuxhaphake kakhulu kunokukhubazeka kwangaphakathi kokujikeleza. Ukuhlolwa kweklinikhi ukuvavanya ukungahambi kakuhle kwangemva kokusebenza kwabikwa ukuba akuchanekanga kwaye kubonise ukulungelelaniswa okuphantsi kunye nokuhlolwa kwe-CT.

Sikholelwa ukuba i-malalignment ihlala iyingxaki yexesha elide kwi-tibial stem fractures ephathwa nge-intramedullary nailing of the tibia. Nangona idatha ephikisanayo malunga nobudlelwane phakathi kokungahambi kakuhle kunye neziphumo zeklinikhi kunye nokucinga, sicebisa ukuba oogqirha kufuneka bazame ukufezekisa ukulungelelaniswa kwe-anatomic yeefractures ukuze kulawulwe oku kuguquguquka kunye nokufumana iziphumo ezilungileyo.

五. Ukuqukumbela

Ukutshixa okumileyo okwandisiweyo kwe-medullary intramedullary nailing kuhlala kulunyango olusemgangathweni lokufuduswa kwe-tibial stem fractures. Indawo yokungena echanekileyo ihlala iyinxalenye ebalulekileyo yenkqubo yotyando. Indlela ye-suprapatellar kwi-semi-extended position ithathwa njengenkqubo ekhuselekileyo nesebenzayo, kwaye izifundo ezizayo kufuneka zihlolisise umngcipheko kunye neenzuzo zale nkqubo. Ugqirha ohambayo kufuneka aqhelane neendlela zangoku zokubuyisela indawo. Ukuba ulungelelwaniso lwe-anatomic fracture alukwazi ukufezekiswa ngendlela evaliweyo, iindlela zokunciphisa i-incisional incision kufuneka ziqwalaselwe. Amazinga okuphilisa okulungileyo ngaphezu kwe-90 % anokufezekiswa kunye nokubethelwa kwe-intramedullary eyandisiweyo kunye ne-non-expanded. Ngaphandle kwamazinga okuphilisa okulungileyo, izigulane zisenemida yokusebenza kwexesha elide. Ngokukodwa, intlungu ye-prepatellar ihlala isikhalazo esiqhelekileyo emva kwe-tibial intramedullary nailing. Ukongezelela, i-malrotation emva kokulungiswa kwe-tibial yangaphakathi ihlala iyingxaki eqhelekileyo.

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