I-Tibial Intramedullary Nail Fixation Technique

Ukulungiswa kwe-Intramedullary nail kusalokhu kungukwelashwa okukhethwa kukho kwe-tibial stem fractures engazinzile futhi esusiwe kubantu abadala. Umgomo wokwelashwa kokuhlinzwa ukubuyisela ubude, ukuqondanisa nokujikeleza kwe-tibia nokufeza ukuphulukiswa kokuphuka. Izinzuzo zokubethelwa kwe-intramedullary ukuhlukumezeka okuncane kokuhlinzwa kanye nokulondolozwa okufanele kokunikezwa kwegazi lapho kuphuka. Ukwengeza, ukubethelwa kwe-intramedullary kwe-tibia kunikeza ukuzinza okufanele kwe-biomechanical fracture futhi kusebenza njengedivayisi yokwabelana ngomthwalo okuvumela ukuhlanganisa ngaphambi kwesikhathi ngemva kokuhlinzwa. Intuthuko ekwakhiweni kwezinzipho ze-intramedullary nezindlela zokunciphisa ziye zandisa izinkomba zokulungiswa kwezinzipho ze-intramedullary ukuze zifake i-proximal tibia kanye nokuqhekeka okuphakathi kwesithathu okuphansi.

Kuze kube yilolu suku, ukulungiswa kwe-intramedullary intramedullary ukunciphisa okuvaliwe kwe-tibial fractures kuye kwaba inqubo evamile yodokotela abahlinzayo bamathambo. Naphezu kokuduma kwe-intramedullary nail fixation for displaced tibial stem fractures, ihlala iyinselele futhi inezinkinga eziningi ezingase zibe khona. Amasu okuhlinza ayaqhubeka nokuvela. Inhloso yalesi sihloko ukuchaza imiqondo yamanje ku-intramedullary nail fixation ye-tibial stem fractures kanye nokufingqa intuthuko yakamuva emkhakheni.

一. Ukuhlola nokuhlolwa kokuqala

Ezigulini ezincane, i-tibial stem fractures ngokuvamile iwumphumela wokulimala okukhulu kwamandla, futhi iziguli kufanele zihlolwe ngokuhlukumezeka okuhambisanayo ngokuvumelana neziqondiso ze-Advanced Trauma Life Support (ATLS). Hlola ukulimala kwesikhumba esizungezile kanye nezicubu ezithambile njengamabhamuza okuphuka, imihuzuko yesikhumba, ukusha, i-ecchymosis, noma ukuphakama kwesikhumba; cacisa ukuthi ukuphuka kuvuliwe, futhi uma kunjalo phatha nge-tetanus kanye nama-antibiotic; futhi wenze ukuhlola okuphelele kwe-neurovascular bese ubhala okungenhla. Linganisa ukuvela kwe-osteofascial compartment syndrome futhi wenze uchungechunge lokuhlolwa komtholampilo kulezi ziguli.

Ucwaningo lwakamuva lubonise ukuthi izehlakalo ze-osteofascial compartment syndrome ezilandela ukuphuka kwe-tibial tuberosity zingase zibe phezulu ku-11.5%. Ikakhulukazi, amaqembu amancane eziguli anamathuba amaningi okuthuthukisa i-osteofascial compartment syndrome. Ukuxilongwa kwe-osteofascial compartment syndrome kufanele kusekelwe ekutholakaleni komtholampilo, okuhlanganisa ubuhlungu obunzima, izinguquko ze-neurovascular, ukuvuvukala kwengxenye ye-myofascial, nobuhlungu obuningi obuvela ekwandisweni kwezinzwane. Ngakho-ke, i-osteofascial compartment syndrome isalokhu ixilongwa emtholampilo futhi imibhalo ephelele yokuhlolwa komtholampilo ibalulekile. Ukucindezela ngaphakathi kwendawo ye-myofascial kungalinganiswa kusetshenziswa inaliti yokucindezela (Umfanekiso 1) njengendlela yokuhlola ehambisanayo ekuhlolweni okukhethekile.

Umfanekiso 1. Ukulinganisa ingcindezi ku-septum engaphakathi kusetshenziswa inaliti yokucindezela.

Ukuze uthole idatha ethembekile, ukucindezela kwe-intrafascial kufanele kulinganiswe ezingxenyeni ezine ze-myofascial nasezindaweni ezihlukene ngaphakathi kwendawo ngayinye ye-myofascial. Ucwaningo ezincwadini lusikisela ukuthi umehluko wengcindezi ongaphansi kuka-30 mmHg (ukucindezela kwe-diastolic minus i-fascial compartment pressure) ubonisa i-fascial compartment syndrome. Ukucindezela kwe-diastolic ngokuvamile kuyehla ngesikhathi sokuhlinzwa, futhi ingcindezi ye-diastolic yangaphambi kokuhlinzwa kufanele icatshangelwe lapho kubalwa ingcindezi yokuhlukanisa.

Ucwaningo lwakamuva lubonise ukuthi ukuqapha kwengcindezi ye-intrafascial kuyithuluzi elingase libe usizo ekuxilongweni kwe-acute fascial compartment syndrome, ngokuzwela okungama-94 % kanye nokucaciswa okungu-98%. Kodwa-ke, uma kucatshangelwa imiphumela engase ibe yingozi ye-compartment syndrome, ukuxilongwa kwe-compartment syndrome kufanele kusekelwe ekutholweni komtholampilo, futhi izilinganiso ze-interosseous compartment pressure kufanele zisetshenziswe ezimweni ezikhethekile, njengalapho isiguli silimale noma lapho amaphuzu edatha yomtholampilo engacacile.

Ukuhlolwa kwesithombe kufanele kufake ama-orthopantomograms ajwayelekile kanye nokubukwa kwe-lateral kwe-tibia elimele kanye nama-radiographs amadolo aseduze namajoyinti e-ankle, abuye ahlolwe kusetshenziswa i-computed tomography (CT). Ngokufanayo, i-CT scan ye-ankle ingase idingeke ukuze ubone ngeso lengqondo imigqa yokuphuka efinyelela ethafeni le-tibial kanye nokulimala kwe-ankle okuhlobene.

二. Izingibe zomtholampilo

Iphesenti eliphezulu lokuphuka kwengxenye yesithathu ephansi ephakathi kwe-tibia ene-ankle fractures kuye kwabikwa. Ukusebenzisa ama-CT scans avamile, i-43% yokuphuka kwengxenye ephakathi nendawo yesithathu ye-tibia yayihambisana nokuphuka kwamaqakala, iningi lawo elidinga ukwelashwa kokuhlinzwa. Uhlobo oluvame kakhulu lokuphuka kwakuwukuphuka okuvunguzayo kwengxenye yesithathu ephakathi ephansi ye-distal tibia ehlotshaniswa nokuphulwa kwe-ankle yangemuva kancane noma engasuswanga (Umfanekiso 2). Ngenxa yokususwa okuncane kokuphuka kwe-ankle okuhlobene, kuphela i-45 % yokulimala ingatholwa kuma-radiographs e-ankle angenalutho. Ngakho-ke, ukuhlolwa kwe-CT okujwayelekile kwe-ankle kufanele kugcizelelwe kakhulu lapho i-tibia ephansi ephakathi nendawo ikhona (Fig. 3).

Umfanekiso 2.AF Ukuphuka okuvunguzayo kwengxenye yesithathu emaphakathi ephansi ye-tibia engakwesokudla (A, B) Ama-radiographs wangaphambi kokuhlinzwa weqakala abonisa okuvamile (C). I-Intraoperative C-arm fluoroscopy ibonisa ukuphuka okungahambi kahle kwe-ankle yangemuva (D) ama-radiographs angemuva kokuhlinzwa ngemva kokulungiswa kokuhlinzwa (EF) kubonisa ukuphulukiswa okushelelayo kokuphuka kwe-tibial kanye ne-ankle

Umfanekiso 3. I-AF Spiral fracture ye-middle and low third ye-left tibia (AB) preoperative radiographs; (CD) izikena ze-CT zangaphambi kokuhlinzwa ezibonisa ukuphuka kwe-posterior malleolar okungenayo indawo; (EF) ebonisa ukuphulukiswa okungenabungozi kwe-tibia kanye nokuphuka kwe-malleolar

三. Izindlela zokuhlinza

01. Indawo Yokungena Yenaliti yaseTibial

Ukusungula indawo yokungena enembile kudlala indima ebalulekile futhi izifundo eziningi ezincwadini zinikeze ulwazi olubalulekile mayelana nendawo ye-anatomical yendawo efanelekile yokungena ye-intramedullary nailing of tibial fractures. Lezi zifundo zibonise ukuthi iphuzu elifanele lokuphina litholakala emaphethelweni angaphambili ethafeni le-tibial futhi livele liphakathi kwe-lateral tibial spur. Indawo yokuphepha enobubanzi obungu-22.9 mm ± 8.9 mm, engadali monakalo ezakhiweni ezihlangene eziseduze, nayo ibikiwe. Ngokwesiko, indawo yokuqala yokulungiswa kwe-intramedullary nail ye-tibial stem fractures isungulwe ngendlela ye-infrapatellar, noma ngokuhlukanisa i-tendon patellar (indlela ye-transpatellar) noma ngokukhipha ingxenye ye-patellar tendon stop (indlela ye-paratendinous).

Ukubethelwa kwe-semi-extension intramedullary kudonse ukunaka okukhulu ezincwadini zakamuva zamathambo, futhi i-Tornetta kanye ne-Collins basikisela ukusebenzisa indlela ye-parapatellar ephakathi ukuze kulungiswe kwangaphakathi isipikili endaweni enwetshiwe emaphakathi ukuze kugwenywe ukuphuma kwe-apex yesipikili se-intramedullary ku-approach yangaphambili ye-tibial cortex for the medial intrame3 I-nail intramedullary. indawo ye-semi-extension nayo iyanconywa. Ukusetshenziswa kwendlela ye-suprapatellar ye-tibial intramedullary nailing kanye nokufakwa kwe-intramedullary nail ngokusebenzisa i-patellofemoral joint in the semi-extended position kunconywa.

Inqubo yenziwa ngedolo eligobile cishe ngama-degree angu-15-20, futhi ukusika i-longitudinal cishe amasentimitha angu-3 kwenziwa cishe ububanzi bomunwe owodwa kuya kwemibili ngaphezu kwe-patella. Ithenda ye-quadriceps ihlukaniswa ngendlela ye-longitudinal futhi i-dissection blunt yenziwa engxenyeni ye-patellofemoral. Isokhethi elingenalutho lifakwe ngokuhlanganyela kwe-patellofemoral ukuze kwakhiwe indawo yokungena ekuhlanganeni kwe-proximal anterior tibial cortex kanye ne-articular surface (Umfanekiso 4).

Umfanekiso 4. ab izithombe ze-intraoperative (a) zokuhlukanisa i-tendon ye-quadriceps nokufaka i-trocar ngokusebenzisa i-patellofemoral joint to the tibial entry point; (b) ukubuka okungemuva kwe-intraoperative kwendawo yokungena

I-drill bit engu-3.2 mm isetshenziselwa ukunquma indawo yenaliti yokuqala ngaphansi kokuqondiswa kwe-C-arm. Isokhethi enezimbobo inikezwa ukuze kulungiswe kahle izindawo zokungena nokuphuma. Izinqubo ezisele zokuhlinza ezihlanganisa ukubuyisela kabusha kanye nokufakwa kwezipikili ze-tibial zenziwa ngesokhethi.

IZINZUZO EZINGASE ziphatheke: Isikhundla somlenze owandisiwe kancane singasiza ekumiseni kabusha ukuphuka, ikakhulukazi ekuqhekekeni okunengxenye yesithathu evamile ye-tibia futhi i-angled phambili. , Isikhundla esinwetshiwe singaqeda ukungezwani kumsipha we-quadriceps futhi sisize ekumiseni kabusha ukuphuka. , Indlela ye-suprapatellar ye-semi-extended position ingase ibe enye indlela yendabuko ye-infrapatellar (Umfanekiso 5).

Umfanekiso 5. Isithombe se-intraoperative esibonisa ukulimala kwezicubu ezithambile endaweni ye-infrapatellar njengenkomba yendlela ye-suprapatellar endaweni enwetshiwe.

Ucwaningo luye lwabonisa ukuthi indlela ye-suprapatellar yokubethelwa kwe-tibial intramedullary endaweni enwetshiwe iyindlela yokuhlinzwa ephephile nephumelelayo. Izivivinyo zemitholampilo zesikhathi esizayo ziyadingeka ukuze kuqhutshekwe kuphenywe izinzuzo nezingozi zendlela ye-suprapatellar nailing intramedullary kanye nokuhlola imiphumela yesikhathi eside ehlobene nale nqubo.

02. Setha kabusha ubuchwepheshe

Ukubekwa kwe-tibial intramedullary nail yedwa akuholeli ekunciphiseni ukuphuka okwanele; ukuncishiswa kwe-fracture efanele kufanele kugcinwe kuyo yonke inqubo yokubuyisela kabusha kanye nokubekwa kwe-intramedullary nail. Ukusetshenziswa kokudonsa ngesandla kukodwa kungase kungaphumeleli njalo ukuncishiswa kwe-anatomic kokuphuka ngokwakho. Lesi sihloko sizochaza izindlela ezihlukahlukene ezivaliwe, ezihlasela kancane, nezivulekile zokunciphisa.

-Amathiphu wokusetha kabusha avaliwe

Ukuqondisa okuvaliwe kokunciphisa kungafezwa ngethuluzi lokunciphisa elifana ne-F-fracture reducer, idivayisi yokunciphisa i-radiographically transmissible emise u-F elungisa ama-engeli okuguqula/ukuguqula kanye nokuhumusha okumaphakathi/okungemuva (Fig. 6).

Umfanekiso 6. Isinciphisi sokuphuka esimise okuka-F esicashunwe ekuhlinzeni

Kodwa-ke, idivayisi ingabeka ukucindezeleka okukhulu ezicutshini ezithambile, futhi ukusetshenziswa isikhathi eside kwalesi sisetshenziswa sokusetha kabusha kufanele kugwenywe. Ama-forceps okunciphisa angabuye abekwe nge-percutaneously, njengasohlangothini lwe-spiral and oblique fractures. Lawa mathuluzi angasetshenziswa ngendlela enobungani nezicubu ezithambile ngokusebenzisa izimbobo ezincane (Umfanekiso 7).

Umfanekiso 7. I-Percutaneous clamping ukusetha kabusha ukuphuka kwe-tibial

Uhlobo lwe-clamp kanye nendawo ye-clamp yokuhlinzwa kufanele kukhethwe ngokusekelwe kwisu lokunciphisa umonakalo wesikhathi eside ezicutshini ezithambile kusukela ekubekweni kwe-clamp (Umfanekiso 8).

Umfanekiso 8. Ama-forceps okubeka kabusha okukhomba ukusetha kabusha ukuphuka kwe-tibial

Ama-retractors nawo angelinye lamathuluzi okusetha kabusha ajwayelekile asetshenziselwa ukubuyisela ubude ku-tibia. Ngokuvamile zibekwe phakathi nendawo futhi kude nendawo lapho i-intramedullary nail idinga ukubekwa khona. Izikhonkwane zokudonsa eziseduze zingabekwa ukuze zilingise indawo yesikulufu esiseduze, esivumela ukuncishiswa okulula kokuphuka uma isipikili se-intramedullary sesingenile.

Kwezinye izimo, amasu okunciphisa avaliwe futhi ahlasela kancane asanele ukuthola ukuncipha kwe-anatomic. Ezimweni ezinjalo, amasu okunciphisa i-incisional kufanele acatshangelwe ngokuphathwa ngokucophelela kwezicubu ezithambile ezizungezile. Ukubi okungase kube khona kwezindlela zokunciphisa okuvulekile zihlanganisa ukuhlukumezeka okwengeziwe kokuhlinzwa, okungase kwandise ingozi yokutheleleka kwendawo yokuhlinzwa. Ukwengeza, ukukhumula okwengeziwe kokunikezwa kwegazi endaweni yokuphuka kungase kwandise ubungozi bokwephulwa kwe-postoperative nonnunion.

-Amakhono obuchwepheshe okusika nokubeka kabusha

Ukuqondisa kokunciphisa i-incision akuvumeli kuphela amandla okunciphisa ukuhlinza abekwe endaweni efanele, kodwa futhi nokusetshenziswa kwama-splints amancane noma amancane endaweni yokuphuka ukuze kugcinwe ukunciphisa ukuphuka phakathi nezinqubo zokubethelwa kwe-intramedullary.

Amapuleti avikelekile ezincekwini zokuphuka eziseduze nezikude kusetshenziswa izikulufu ze-monocortical. I-splint igcinwa kuyo yonke inqubo yokubuyisela kabusha nokubekwa kwe-intramedullary nail ku-tibia. Ngemuva kokubekwa kwe-intramedullary nail, ipuleti lisusiwe noma lishiywe endaweni ukuze kuthuthukiswe ukuzinza kwesakhiwo esimisiwe (Umfanekiso 9). Ngokushiya ipuleti lisendaweni, isikulufu se-cortical single kufanele sishintshwe nesikulufu se-cortical double. Kufanele kucatshangelwe ukuthi kusetshenziswe ezimweni ezikhethiwe lapho isiqu se-tibial sidinga ukuhlinzwa okuvulekile ukuze kuzuzwe ukunciphisa ukuphuka okwamukelekayo.

Umfanekiso 9. Vula i-tibia fracture nge-comminution enzima kanye ne-bone defect, ukulungiswa kwe-cortical eyodwa nge-splint encane ekugcineni okuphukile kokuphuka ngemva kokunciphisa nokususwa kwe-splint ngemva kokulungiswa kwe-intramedullary nail.

Inhloso ye-nail evimbelayo ukunciphisa i-medullary cavity esifundeni se-metaphyseal. Izipikili ezivimbelayo zifakwe ngaphakathi kwesiqephu esifushane se-articular kanye nasohlangothini lwe-concave lokukhubazeka ngaphambi kokubekwa kwe-intramedullary nail. Isibonelo, ukukhubazeka okuvamile kokuphuka kwe-proximal third ye-tibia kubonakala nge-valgus ne-angulation phambili. Ukuze ulungise ukukhubazeka kwe-valgus, isikulufu sokukhiya singafakwa engxenyeni engemuva yesiqephu sokuphuka esiseduze (okungukuthi, uhlangothi lwe-concave lokukhubazeka) ku-anteroposterior direction. I-nail ye-intramedullary iqondiswa kusukela ohlangothini oluphakathi, ngaleyo ndlela ivimbele i-valgus. Ngokufanayo, ukukhubazeka kwe-angulation kunganqotshwa ngokubeka isikulufu sokukhiya esiphakathi nendawo ukuya engxenyeni engemuva ye-proximal block (okungukuthi, uhlangothi lwe-concave lokukhubazeka) (Umfanekiso 10).

Umfanekiso 10. Ukusetha kabusha okusizwayo kokuphuka kwe-tibial ngokubeka izipikili ezivimbelayo

-Ukunwetshwa kwesikhashana

Ngemva kokuqeda ukubekwa kabusha kwe-fracture, i-medullary reaming ikhethwa ukuze kulungiswe ithambo lokufakwa kwe-intramedullary nail. I-ball-ended guidewire ifakwa emgodini womnkantsha we-tibial nasendaweni yokuphuka, futhi i-reaming drill idluliswa phezu kwe-ball-ended guidewire. Ukuma kwe-ball-ended guidewire kwaqinisekiswa ngaphansi kwe-C-arm fluoroscopy ukuze ibe sezingeni le-ankle joint, futhi i-guidewire yayigxile kahle kukho kokubili ukubukwa kwe-anteroposterior kanye ne-lateral (Umfanekiso we-11).

Umfanekiso 11. ubonisa indawo ye-guidewire ku-medullary cavity ku-C-arm fluoroscopy endaweni yangaphambili neseceleni.

Indaba yokunwetshwa kwe-medulla enganwetshiwe ibe yimpikiswano. Sikholelwa ukuthi odokotela abaningi abahlinzayo eNyakatho Melika bakhetha ukubethelwa kwe-medullary intramedullary okunwetshiwe kwe-tibia ukuze kunganwetshwa. Kodwa-ke, kokubili ukubethelwa kwe-intramedullary okunwetshiwe nokunganwetshiwe kungasetshenziswa njengamasu ajwayelekile amukelekayo, futhi imiphumela emihle ingatholakala ngazo zombili izindlela.

- Ukubekwa kwesikulufa sokukhiya

Ukusetshenziswa kwezikrini ezihlanganisiwe ekuqhekekeni kwe-tibial stem kuhloswe ukuvimbela ukufinyezwa nokungahambi kahle, ukwandisa izinkomba zokubethelwa kwe-intramedullary ye-tibia kuya ekuqhekekeni kwe-tibial stem okuseduze kakhulu ne-distal okubandakanya i-metaphysis. Ekuqhekekeni okubandakanya isifunda se-metaphyseal, izikulufu ezixhumene zabaluleka kakhulu ekugcineni ukuqondanisa kwe-axial.

Izikulufu ezintathu ezisondelene ezisondelene zithuthukise kakhulu ukuzinza, futhi izikulufu ezixhumene ezimile-engeli zinganikeza ukuzinza okukhulu kunezikulufu ezijwayelekile ezingenelayo, ezingase zivumele ukuqina kwesakhiwo okufanayo ukuthi kutholwe ngenani elincane lezikulufu ezixhumene. Idatha yomtholampilo ngenombolo kanye nokucushwa kwezikulufu ezihlanganisiwe ezidingekayo ukuze kulungiswe kwangaphakathi i-tibia kuhlala kunomkhawulo.

Ukubekwa kwezikulufu ezisondelene ezixhumene kuvame ukwenziwa kusetshenziswa isikophu esinamathiselwe ku-intramedullary nail spike. Izikulufu ezi-distal interlocking zifakwa mahhala ngaphansi kokuqondisa kwe-fluoroscopic. Ukusetshenziswa kwesistimu yokuqondisa okusizwa ngogesi kagesi kuyanconywa ukuze kufakwe izikulufu ezihlanganayo ze-distal tibial (Umfanekiso 12). Le nqubo ivumela ukufakwa ngaphandle kwemisebe kwezikulufu ezixhumene ezikude futhi kuboniswe ukuthi kuyindlela engenzeka nenembile.

Umfanekiso 12.AB Izikulufu zokukhiya ngokubuka kwengalo ye-C; Izikulufu zokukhiya i-CD ngokukhiya okusizwa yikhompyutha ngogesi

Ukubekwa kwezikulufu ezixhumene eziseduze ne-distal kuyinqubo yokuhlinzwa ephephile futhi izikulufu ezixhumene kufanele zifakwe ngendlela enembile nethambile izicubu ezinobungane.

Ucwaningo lwe-anatomic lubonise ukuthi kusenengozi yokuba ne-peroneal nerve palsy lapho kubekwa izikulufu ezixhumene ezimaphakathi ne-oblique ezingemuva. Ukuze unciphise le ngozi, odokotela abahlinzayo kufanele bacabangele ukubhoboza izikulufu ngaphansi kokuqondisa kwe-C-arm, nge-engeli ye-fluoroscopic ye-C-arm perpendicular endizeni yebhithi yokubhoboza. Ukungena kwe-drill ku-cortex ye-distal tibia kungase kube nzima ukukubona ngempendulo ethintekayo, futhi ukusondelana kwekhanda le-fibula kungase kufihle umbono othintekayo futhi kunikeze udokotela ohlinzayo umbono wokuthi 'usethanjeni' kuyilapho empeleni ikhanda le-fibular selingenisiwe. Ubude bezikulufu akufanele bunqunywe kuphela ngokubhola okuphothuliwe kodwa futhi nangezilinganiso ezifanele zegeji yokujula. Noma isiphi isilinganiso sobude bokubhoboza noma isikulufu esikhulu kuno-60 mm kufanele siphakamise ukusola kwe-posterolateral protrusion, okungase kubeke umsipha ovamile engozini yokulimala.

Izikulufu ezixhumene ezikude zangaphambili nangemuva zibekwe ngokunaka ekuvikelweni kwe-anterolateral neurovascular bundle, i-tibialis anterior tendon, kanye ne-extensor digitorum longus. Nakuba ukufakwa kwesikulufa se-percutaneous ngokuvamile kuphephile, odokotela abahlinzayo kudingeka baqaphele ubungozi bezakhiwo ezizungezile zezicubu ezithambile. Ezingxenyeni eziningi ze-tibial stem fractures, izikulufu ezimbili ezisondelene nezibili ezikude zinikeza ukuzinza okwanele. I-Proximal and distal fractures ye-tibial ingase izuze ekubekweni kwezikulufu ezengeziwe ezihlanganisiwe ezindizeni ezahlukene ukuze kwandiswe ukuzinza kwalesi sakhiwo (Umfanekiso 13).

Umfanekiso 13. Ukuphuka kaningi kwe-tibia, kuphathwe ngokubethelwa kwe-intramedullary ngezikulufu ezimbili ezikude nezintathu ezisondelene ezixhumene, nama-x-ray alandelayo aphakamisa ukuphulukiswa kokuphuka.

- Ukulungiswa kwe-Fibular

Imiklamo yesimanje yezinzipho ze-intramedullary enezikulufu ezixhumene ezikude zandise izinkomba zokubethelwa kwe-intramedullary ye-tibia ukuze kufakwe ukuphuka okuseduze nokukude okubandakanya isifunda se-metaphyseal.

Kusetshenziswe izikulufu ezihlukene ze-distal interlocking screw ocwaningweni (izikulufu ezi-2 ukusuka kwemaphakathi kuya kwesemuva kuya kwezingu-2 ezibekwe eceleni kwesinye nesinye kanye nesamba sezikulufu ezi-3 ezihlukanisayo ezikude uma kuqhathaniswa nesikulufu esi-1 se-distal interlocking). Ezigulini ezathola ukulungiswa kwe-fibular kanye ne-tibial intramedullary nail fixation, izinga lokusetha kabusha okulahlekile laliphansi kakhulu. Ingqikithi ye-13 % yeziguli ezine-intramedullary nail fixation ngaphandle kokulungiswa kwe-fibular yabonisa ukulahlekelwa ngemuva kokuhlinzwa kokusetha kabusha, uma kuqhathaniswa ne-4 % yeziguli ezine-tibial nail fixation ngaphandle kokulungiswa kwe-fibular.

Kwesinye isilingo esiqhathanisa ukusebenza kahle kwe-tibial intramedullary nail fixation ngokumelene ne-fibular fixation kanye ne-tibial intramedullary nail fixation ngokumelene nokulungiswa kwe-fibular, iziguli eziphathwe nge-fibular fixation ngokuhambisana ne-tibial nailing zibonise ukuthuthukiswa kokujikeleza nokuguquguquka / ukulungiswa kwe-eversion.

Siphetha ngokuthi ukulungiswa kwe-fibular okuhambisanayo kufeza futhi kugcina ukuncishiswa kwe-tibial fracture kuma-distal one-third tibia fractures okwenziwa ukulungiswa kwe-intramedullary nail. Kodwa-ke, inkinga yezinkinga zezilonda ezivela ekusikeni okwengeziwe endaweni yezicubu ezihlukumezekile zihlala. Ngakho-ke sincoma ukuqaphela ekusebenziseni ukulungiswa kwe-fibular okusizwayo.

03. Imiphumela

Ukulungiswa kwe-Intramedullary nailing of tibial stem fractures kungaveza imiphumela emihle. Amazinga okuphulukisa we-intramedullary nailing of the tibia abikwe ezifundweni ezahlukene. Ngokusetshenziswa kwezimila zesimanje nezindlela ezifanele zokuhlinza, amazinga okuphulukisa kulindeleke ukuba adlule ku-90%. Izinga lokuphulukisa le-tibial stem fractures elihlulekile ukuphulukiswa ngemva kokulungiswa kwe-intramedullary nail lathuthukiswa ngokuphawulekayo ngemva kokulungiswa kwangaphakathi nge-nail yesibili eyandisiwe ye-intramedullary.

Ukuhlolwa komphumela ngonyaka owodwa ngemva kokuhlinzwa kwabonisa ukuthi kuze kufike ku-44 % weziguli ziqhubekile nokuba nemingcele yokusebenza endaweni ephansi elimele, futhi kuze kufike ku-47 % yaqhubeka nokubika ukukhubazeka okuhlobene nomsebenzi ngonyaka owodwa ngemva kokuhlinzwa. Ucwaningo lubonisa ukuthi iziguli eziphathwa nge-intramedullary nailing of the tibia ziqhubeka zinemikhawulo ebalulekile yokusebenza esikhathini eside. Odokotela abahlinzayo kufanele bazazi lezi zinkinga futhi beluleke iziguli ngokufanele!

四. Izinkinga zangemva kokuhlinzwa

01. Ubuhlungu be-pre-patellar

Ubuhlungu be-patellofemoral obungaphambili buyinkinga evamile ngemva kokulungiswa kwezipikili ze-intramedullary ze-tibial stem fractures. Ucwaningo luye lwabonisa ukuthi cishe i-47% yeziguli ngemva kokubethelwa kwe-intramedullary ingase ihlakulele ubuhlungu be-prepatellar, i-etiology yayo engaqondakali ngokugcwele. Izici ezingaba nomthelela zingase zihlanganise ukulimala okudabukisayo kanye nezokwelapha ezakhiweni ze-intra-articular, ukulimala kwegatsha le-infrapatellar le-saphenous nerve, ubuthakathaka bemisipha yethanga yesibili ekucindezelweni kwe-neuromuscular reflexes ehlobene nobuhlungu, i-fibrosis ye-fat pad eholela ekufakweni, i-patellar tendonitis esebenzayo, ukugoba phezu kwe-produlla ye-produlla, ukugoba phezu kwe-produlla ye-produlla. ukuphumela kokuphela kwesipikili.

Lapho kufundwa i-etiology yobuhlungu be-prepatellar ngemuva kokubethelwa kwe-intramedullary, indlela ye-transpatellar tendon yaqhathaniswa nendlela ye-parapatellar. Indlela ye-transpatellar tendon ingase ihlotshaniswe nesigameko esiphezulu sobuhlungu be-postoperative edolo. Kodwa-ke, idatha yomtholampilo engahleliwe ayizange ibonise umehluko obalulekile phakathi kwendlela ye-transpatellar tendon kanye nendlela ye-parapatellar.

Ukusebenza kokususwa okukhethiwe kokulungiswa kwangaphakathi ukubhekana nobuhlungu be-prepatellar ngemuva kwe-tibial intramedullary nailing akuqinisekisiwe. Sincoma ukuthi ukukhishwa kwe-intramedullary tibial nail kucatshangelwe uma i-etiology yomshini ingase ibonakale, njenge-protrusion yezinzipho noma isikulufu esixhumene esivele siphumele ngaphandle. Kodwa-ke, inzuzo yokususwa kwezipikili ze-tibial intramedullary ezigulini ezinezimpawu zihlala zingabazeka.

Ngokuphathelene nobuhlungu be-postoperative prepatellar, imbangela yobuhlungu ayikwazanga ukuboniswa ngokucacile esifundweni sokuqala somtholampilo we-intramedullary nail fixation of the tibial nail on the patella in the semi-extended position. Ngakho-ke, izifundo ezinkulu zemitholampilo ezinokulandelela isikhathi eside ziyadingeka ukuze kuqinisekiswe umphumela wokulungiswa kwezipikili ze-intramedullary endleleni ye-suprapatellar ebuhlungu be-postoperative prepatellar.

02.Ukungahambi kahle kwangemuva kokuhlinzwa

I-post-traumatic osteoarthritis iseyinkinga ebalulekile ngemva kokwelashwa kwe-tibial stem fractures nge-intramedullary nailing. Ucwaningo lwe-biomechanical lubonise ukuthi ukungahambi kahle kwe-tibial kungase kubangele izinguquko eziphawulekayo ekucindezelweni kokuxhumana emaqakaleni aseduze namadolo.

Ucwaningo lwezokwelapha oluhlola imiphumela yesikhathi eside yomtholampilo kanye ne-imaging ngemva kokuhlukana kwe-tibial stem inikeze idatha ephikisanayo mayelana ne-sequelae ye-tibial malalignment, ngaphandle kweziphetho ezicacile kuze kube manje.

Imibiko ye-postoperative malalignment ngemuva kokubethelwa kwe-intramedullary ye-tibia ihlala ilinganiselwe, nenani elincane lamacala abikiwe. I-postoperative malrotation ihlala iyinkinga evamile ku-tibial intramedullary nailing, futhi ukuhlolwa kwe-intraoperative ukujikeleza kwe-tibial kuhlala kuyinselele. Kuze kube manje, akukho ukuhlolwa komtholampilo noma indlela yokucabanga esungulwe njengezinga legolide lokunqunywa kwe-intraoperative ye-tibial rotation.Ukuhlolwa kokuhlolwa kwe-CT kubonise ukuthi izinga lokungalungi ngemva kokubethelwa kwe-intramedullary ye-tibia lingase libe phezulu ku-19 % kuya ku-41%. Ikakhulukazi, ukukhubazeka kokujikeleza kwangaphandle kubonakala kuvame kakhulu kunokukhubazeka kwangaphakathi kokujikeleza. Ukuhlolwa komtholampilo ukuze kuhlolwe ukungasebenzi kahle kwangemva kokuhlinzwa kwabikwa ukuthi akunembile futhi kwabonisa ukuhlobana okuphansi nokuhlolwa kwe-CT.

Sikholelwa ukuthi ukungalungi kahle kuhlala kuyinkinga yesikhathi eside ekuqhekekeni kwe-tibial stem ephathwa nge-intramedullary nailing of the tibia. Naphezu kwedatha ephikisanayo mayelana nobuhlobo phakathi kokungahambi kahle kanye nemiphumela yomtholampilo kanye ne-imaging, siphakamisa ukuthi odokotela abahlinzayo kufanele balwele ukufeza ukuqondanisa kwe-anatomic kwama-fractures ukuze kulawulwe lokhu kuguquguquka futhi bathole imiphumela emihle.

五. Isiphetho

Ukukhiya okumile okunwetshiwe kwe-medullary intramedullary nailing kusalokhu kungukwelashwa okujwayelekile kokuqhekeka kwe-tibial stem fractures. Indawo yokungena efanele ihlala iyingxenye ebalulekile yenqubo yokuhlinzwa. Indlela ye-suprapatellar endaweni enwetshiwe ibhekwa njengenqubo ephephile nephumelelayo, futhi izifundo zesikhathi esizayo zidinga ukuqhubeka nokuhlola izingozi nezinzuzo zale nqubo. Udokotela ohlinzayo ohambelayo kufanele ajwayelane nezindlela zanamuhla zokubeka kabusha indawo. Uma ukulungiswa kwe-anatomic fracture kungenakufinyelelwa ngendlela evaliwe, amasu okunciphisa ama-incisional kufanele acatshangelwe. Amazinga amahle okuphulukisa angaphezu kwama-90 % angafinyelelwa ngokubethelwa kwe-intramedullary okunwetshiwe nokunganwetshiwe. Naphezu kwamazinga amahle okuphulukisa, iziguli zisenemikhawulo yokusebenza yesikhathi eside. Ikakhulukazi, ubuhlungu be-prepatellar buhlala buyisikhalazo esivamile ngemva kwe-tibial intramedullary nailing. Ukwengeza, i-malrotation ngemva kokulungiswa kwangaphakathi kwe-tibial ihlala iyinkinga evamile.

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