I-Navicular malunion yenzeka cishe ku-5-15% wabo bonke abaphukile bethambo le-navicular, kanti i-navicular necrosis yenzeka cishe ku-3%. Izici eziyingozi ze-navicular malunion zifaka phakathi ukuxilongwa okungafanele noma okulibazisekile, ukusondela komugqa wokuqhekeka, ukufuduka okungaphezu kwe-1 mm, kanye nokuqhekeka okubangelwa ukungazinzi kwe-carpal. Uma ingelashwa, i-navicular osteochondral nonunion ivame ukuhlotshaniswa ne-traumatic arthritis, eyaziwa nangokuthi i-navicular osteochondral nonunion ene-osteoarthritis ewayo.
Ukufakelwa kwamathambo nge-flap enemithambo yegazi noma ngaphandle kwayo kungasetshenziswa ukwelapha i-navicular osteochondral nonunion. Kodwa-ke, ezigulini ezine-osteonecrosis ye-proximal pole yethambo le-navicular, imiphumela yokufakelwa kwamathambo ngaphandle kwe-thrombo yemithambo yegazi ayanelisi, futhi izinga lokuphulukiswa kwamathambo lingu-40%-67 kuphela. Ngokuphambene nalokho, izinga lokuphulukiswa kwama-bone grafts ane-thrombo yemithambo yegazi lingafinyelela ku-88%-91%. Ama-bone flaps amakhulu anemithambo yegazi emisebenzini yezokwelapha afaka i-1,2-ICSRA-tipped distal radius flap, i-bone graft + vascular bundle implant, i-palmar radius flap, i-free iliac bone flap ene-thrombo yemithambo yegazi, kanye ne-medial femoral condylar bone flap (MFC VBG), njll. Imiphumela yokufakelwa kwamathambo nge-thrombo yemithambo yegazi iyanelisa. I-MFC VBG yamahhala iboniswe ukuthi iyasebenza ekwelapheni ama-navicular fractures ane-metacarpal collapse, kanti i-MFC VBG isebenzisa igatsha le-articular le-descending knee artery njengegatsha eliyinhloko le-trophic. Uma kuqhathaniswa nezinye izimbobo, i-MFC VBG inikeza ukwesekwa okwanele kwesakhiwo ukubuyisela isimo esijwayelekile sethambo le-navicular, ikakhulukazi ku-osteochondrosis yokuphuka kwe-navicular enokukhubazeka komhlane ogobile (Isithombe 1). Ekwelapheni i-osteochondral osteonecrosis ye-navicular ene-progressive carpal collapse, i-1,2-ICSRA-tipped distal radius flap ibikwe ukuthi inesilinganiso sokuphulukiswa kwethambo esingu-40% kuphela, kanti i-MFC VBG inesilinganiso sokuphulukiswa kwethambo esingu-100%.
Isithombe 1. Ukuphuka kwethambo le-navicular elinokukhubazeka "okugobile emuva", i-CT ikhombisa ibhulokhi lokuqhekeka phakathi kwamathambo e-navicular nge-engeli engaba ngu-90°.
Ukulungiselela ngaphambi kokuhlinzwa
Ngemva kokuhlolwa ngokomzimba kwesandla esithintekile, izifundo zezithombe kumele zenziwe ukuze kuhlolwe izinga lokuwa kwesandla. Ama-radiograph alula awusizo ukuqinisekisa indawo yokuphuka kwesandla, izinga lokufuduka, kanye nokuba khona kwe-resorption noma i-sclerosis yengxenye ephukile. Izithombe zangaphambili ezingemuva zisetshenziselwa ukuhlola ukuwa kwesandla, ukungahlaliseki kwesandla (DISI) kusetshenziswa isilinganiso sokuphakama kwesandla esishintshiwe (ukuphakama/ububanzi) esingu-≤1.52 noma i-radial lunate angle engaphezu kuka-15°. I-MRI noma i-CT ingasiza ekuxilongeni ukungalungi kwethambo le-navicular noma i-osteonecrosis. Ama-radiograph aseceleni noma i-CT ye-oblique sagittal yethambo le-navicular ene-angle ye-navicular >45° iphakamisa ukufinyezwa kwethambo le-navicular, okwaziwa ngokuthi "ukukhubazeka komhlane ogobile". I-MRI T1, isibonakaliso esiphansi se-T2 siphakamisa i-necrosis yethambo le-navicular, kodwa i-MRI ayinalo ukubaluleka okusobala ekunqumeni ukuphulukiswa kokuphuka.
Izinkomba kanye ne-contraindications:
Ukungasebenzi kahle kwe-osteochondral ye-navicular okunokukhubazeka komhlane ogobile kanye ne-DISI; I-MRI ikhombisa i-ischemic necrosis yethambo le-navicular, ukukhululeka kwe-tourniquet ngesikhathi sokuhlinzwa kanye nokubona ukuphuka okuphukile kwengxenye ephukile yethambo le-navicular kuseyithambo elimhlophe le-sclerotic; ukwehluleka kokufakelwa kwethambo lokuqala noma ukufakwa kwangaphakathi kwesikulufo kudinga i-VGB structural bone grafting enkulu (> 1cm3). okutholakele ngaphambi kokuhlinzwa noma ngaphakathi kokuhlinzwa kwe-osteoarthritis ye-radial carpal joint; uma kwenzeke i-navicular malunion ebalulekile ene-osteoarthritis ewayo, khona-ke i-wrist denervation, i-navicular osteotomy, i-quadrangular fusion, i-proximal carpal osteotomy, i-total carpal fusion, njll., kungadingeka; i-navicular malunion, i-proximal necrosis, kodwa ngesimo sethambo se-navicular esijwayelekile (isb., ukuphuka kwe-navicular okungasuswanga ngokunikezwa kwegazi okungekuhle e-proximal pole); ukufinyezwa kwe-navicular malunion ngaphandle kwe-osteonecrosis. (I-1,2-ICSRA ingasetshenziswa esikhundleni se-distal radius flap).
I-Anatomy Esetshenzisiwe
I-MFC VBG ihlinzekwa yimithambo emincane ye-trophoblastic exubene (isilinganiso esingu-30, 20-50), lapho igazi eliningi kakhulu lingaphansi ngemuva kune-medial femoral condyle (isilinganiso esingu-6.4), kulandelwe yi-anteriorly superior (isilinganiso esingu-4.9) (Isithombe 2). Le mithambo ye-trophoblastic ihlinzekwa kakhulu yi-descending geniculate artery (DGA) kanye/noma i-superior medial geniculate artery (SMGA), okuyigatsha le-superficial femoral artery eliphinde liveze amagatsha e-articular, musculocutaneous, kanye/noma saphenous nerve. I-DGA yavela kumthambo we-femoral ongaphezulu oseduze nokuphakama kwe-medial malleolus, noma ebangeni elingu-13.7 cm eduze nobuso be-articular (10.5-17.5 cm), futhi ukuzinza kwe-branching kwakungu-89% kuma-cadaveric specimens (Isithombe 3). I-DGA ivela kumthambo we-femoral ongaphezulu ongu-13.7 cm (10.5 cm-17.5 cm) eduze komfantu we-medial malleolus noma eduze kobuso be-articular, kanye nesampula yesidumbu esibonisa ukuqina kwamagatsha angu-100% kanye nobubanzi obungaba ngu-0.78 mm. Ngakho-ke, i-DGA noma i-SMGA iyamukeleka, yize owokuqala ufaneleka kakhulu i-tibiae ngenxa yobude nobubanzi bomthambo.
Isithombe 2. Ukusatshalaliswa kwemithambo ye-MFC trophoblast enama-quadrant amane emgqeni ovundlile phakathi kwe-semitendinosus kanye ne-medial collateral ligament A, umugqa we-greater trochanter B, umugqa we-superior pole ye-patella C, umugqa we-anterior meniscus D.
Isithombe 3. Ukwakheka kwemithambo yegazi ye-MFC: (A) Amagatsha angavamile kanye nokwakheka kwemithambo yegazi ye-MFC trophoblastic, (B) Ibanga lemvelaphi yemithambo yegazi kusukela emugqeni ohlangene
Ukufinyelela kokuhlinzwa
Isiguli sibekwe ngaphansi kwe-anesthesia ejwayelekile endaweni yokulala phansi, kanti isitho esithintekile sibekwe etafuleni lokuhlinzwa kwesandla. Ngokuvamile, i-donor bone flap ithathwa ku-ipsilateral medial femoral condyle, ukuze isiguli sikwazi ukuhamba ngezinduku ngemuva kokuhlinzwa. Idolo eliphambene nalo lingakhethwa uma kunomlando wokulimala noma ukuhlinzwa kwangaphambilini ohlangothini olufanayo lwedolo. Idolo liyagoba futhi isinqe sijikeleziswa ngaphandle, futhi ama-tourniquet asetshenziswa kokubili emilenzeni ephezulu nangaphansi. Indlela yokuhlinzwa kwakuyindlela ende ye-Russe, lapho ukusikwa kuqala ngo-8 cm eduze komhubhe we-carpal ophambene futhi kunwebeka kude nomphetho we-radial we-radial flexor carpi radialis tendon, bese kugoqwa emhubheni we-carpal ophambene kuya phansi kwesithupha, kuphele ezingeni le-trochanter enkulu. Isigxobo se-tendon se-radial longissimus tendon siyanqunywa bese i-tendon idonswa ulnar, bese ithambo le-navicular livezwa ngokuqhekeka okubukhali eceleni kwe-radial lunate kanye ne-radial navicular head ligaments, ngokuhlukaniswa ngokucophelela kwezicubu ezithambile ezingaphandle kwethambo le-navicular ukuze kuvunyelwe ukuvezwa okwengeziwe kwethambo le-navicular (Isithombe 4). Qinisekisa indawo yokungahlangani, ikhwalithi ye-articular cartilage kanye nezinga le-ischaemia yethambo le-navicular. Ngemva kokukhulula i-tourniquet, bheka i-proximal pole yethambo le-navicular ukuze uthole ukuphuma kwegazi ukuze kutholakale ukuthi kukhona yini i-ischemic necrosis. Uma i-navicular necrosis ingahlotshaniswa ne-radial carpal noma i-intercarpal arthritis, i-MFC VGB ingasetshenziswa.
Isithombe 4. Indlela yokuhlinzwa kwe-navicular: (A) Ukusikwa kuqala ngo-8 cm eduze komhubhe we-carpal ophambene futhi kwandise umphetho we-radial we-radial flexor carpi radialis tendon engxenyeni ekude yokusikwa, egoqwa ibheke phansi kwesithupha emhubheni we-carpal ophambene. (B) Isigxobo se-tendon se-radial longissimus tendon siyasikwa bese i-tendon idonswa ulnar, bese ithambo le-navicular livezwa ngokusikwa okubukhali eceleni kwe-radial lunate kanye ne-radial navicular head ligaments. (C) Thola indawo yokungaqhubeki kwe-navicular osseous.
Kwenziwa ukusika okungamasentimitha angu-15-20 ubude eduze komugqa wedolo eceleni komngcele ongemuva wemisipha ye-medial femoral, bese imisipha ihoxiswa ngaphambili ukuze kuvele igazi le-MFC (Isithombe 5). Ukunikezwa kwegazi le-MFC ngokuvamile kunikezwa ngamagatsha ahlangene e-DGA kanye ne-SMGA, ngokuvamile kuthatha igatsha elikhulu elihlangene le-DGA kanye nomthambo ohambisanayo. I-pedicle yemithambo yegazi iyakhululwa eduze, inakekela ukuvikela i-periosteum kanye nemithambo ye-trophoblastic ebusweni bethambo.
Isithombe 5. Ukufinyelela ngokuhlinzwa ku-MFC: (A) Kwenziwa ukusika okungu-15-20 cm ubude eduze komngcele ongemuva wemisipha ye-medial femoral kusuka emgqeni wejoyinti ledolo. (B) Imisipha ihoxiswa ngaphambili ukuze kuvele igazi le-MFC.。
Ukulungiswa kwethambo le-navicular
Ukukhubazeka kwe-navicular DISI kumele kulungiswe futhi indawo ye-osteochondral bone graft ilungiswe ngaphambi kokufakelwa ngokugoba isihlakala ngaphansi kwe-fluoroscopy ukuze kubuyiselwe i-radial lunate angle evamile (Isithombe 6). Iphini likaKirschner elingamamitha angu-0.0625 (cishe u-1.5-mm) libhobozwa nge-percutaneously kusukela emhlane kuya e-metacarpal ukuze kulungiswe i-radial lunate joint, futhi i-navicular malunion gap iyavezwa lapho isihlakala siqondiswa. Isikhala sokuqhekeka sasuswa izicubu ezithambile futhi savulwa nge-plate spreader. Kusetshenziswa isaha elincane elijikelezayo ukuze kuncishiswe ithambo futhi kuqinisekiswe ukuthi i-implant flap ifana kakhulu nesakhiwo esingunxande kune-wedge, okudinga ukuthi i-navicular gap iphathwe ngesikhala esikhulu ohlangothini lwesundu kunasohlangothini lwe-dorsal. Ngemva kokuvula isikhala, isici silinganiswa ngezinga ezintathu ukuze kutholakale ubukhulu be-bone graft, evame ukuba ngu-10-12 mm ubude kuzo zonke izinhlangothi ze-graft.
Isithombe 6. Ukulungiswa kokukhubazeka komhlane ogobile we-navicular, ngokugoba kwesandla nge-fluoroscopic ukuze kubuyiselwe ukulingana okuvamile kwe-radial-lunar. Iphini likaKirschner elingamamitha angu-0.0625 (cishe u-1.5-mm) libhobozwa nge-percutaneously kusukela emhlane kuya ku-metacarpal ukuze kulungiswe i-radial lunate joint, okuveza igebe le-navicular malunion futhi kubuyiselwe ukuphakama okuvamile kwethambo le-navicular lapho isihlakala siqondile, kanye nosayizi wegebe obikezela usayizi we-flap okuzodinga ukuvinjelwa.
Ukuhlinzwa kwe-Osteotomy
Indawo enemithambo yegazi ye-medial femoral condyle ikhethwa njengendawo yokukhipha amathambo, futhi indawo yokukhipha amathambo iphawulwe ngokwanele. Qaphela ukuthi ungalimazi i-medial collateral ligament. I-periosteum iyasikwa, bese kuthi i-bone flap engunxande enobukhulu obufanele be-flap oyifunayo isikwe ngesaha elijikelezayo, bese kusikwa i-bone block yesibili ku-45° ohlangothini olulodwa ukuqinisekisa ubuqotho be-flap (Isithombe 7). 7). Kufanele kuqashelwe ukuthi ungahlukanisi i-periosteum, i-cortical bone, kanye ne-cancellous bone ye-flap. I-tourniquet engezansi kufanele ikhishwe ukuze kubonwe ukugeleza kwegazi nge-flap, futhi i-vascular pedicle kufanele ikhululwe eduze okungenani amasentimitha ayi-6 ukuze kuvunyelwe i-vascular anastomosis elandelayo. Uma kudingeka, inani elincane le-cancellous bone lingaqhubeka ngaphakathi kwe-femoral condyle. I-femoral condylar defect igcwaliswa nge-bone graft substitute, bese i-incision ikhishwa amanzi bese ivalwa ungqimba ngengqimba.
Isithombe 7. Ukususwa kwe-MFC bone flap. (A) Indawo ye-osteotomy eyanele ukugcwalisa isikhala se-navicular imakwe, i-periosteum iyasikwa, bese kunqunywa i-bone flap engunxande enobukhulu obufanele be-flap oyifunayo ngesaha elijikelezayo. (B) Ingxenye yesibili yethambo iyanqunywa ohlangothini olulodwa ku-45° ukuqinisekisa ubuqotho be-flap.
Ukufakelwa kwe-flap kanye nokulungiswa kwayo
I-bone flap inqunywa ibe nesimo esifanele, kuqikelelwe ukuthi ayicindezeli i-vascular pedicle noma isuse i-periosteum. I-flap ifakwa kancane endaweni ye-navicular bone defect, kugwenywe ukushaywa, bese iqiniswa ngezikulufo ze-navicular ezingenalutho. Kuqikelelwe ukuqinisekisa ukuthi umkhawulo wesundu we-bone block efakiwe uhlanjululwe ngomkhawulo wesundu wethambo le-navicular noma ukuthi ucindezelwe kancane ukuze kugwenywe ukuminyana. Kwenziwa i-fluoroscopy ukuqinisekisa ukuma kwethambo le-navicular, umugqa wamandla kanye nendawo yesikulufo. Hlunga umthambo we-vascular flap uye emthanjeni we-radial ohlangothini kanye ne-venous tip iye emthanjeni we-radial ohambisana nomthambo kusukela ekuqaleni kuya ekugcineni (Isithombe 8). I-joint capsule iyalungiswa, kodwa i-vascular pedicle iyagwenywa.
Isithombe 8. Ukufakelwa kwethambo, ukuqina, kanye ne-vascular anastomosis. Ithambo lifakwa ngobumnene endaweni ye-navicular bone defect bese liqiniswa ngezikulufo ze-navicular ezingenalutho noma izikhonkwane ze-Kirschner. Kuyaqashelwa ukuthi umkhawulo we-metacarpal we-bone block efakiwe ugobile nomkhawulo we-metacarpal wethambo le-navicular noma ucindezelwe kancane ukuze kugwenywe ukuthinteka. I-Anastomosis yomthambo we-vascular flap oya emthanjeni we-radial yenziwa kusukela ekuqaleni kuze kube sekupheleni, kanti umkhawulo womthambo oya emthanjeni we-radial artery ohambisana nawo wenziwa kusukela ekuqaleni kuze kube sekupheleni.
Ukuvuselelwa ngemva kokuhlinzwa
I-aspirin yomlomo engu-325 mg ngosuku (inyanga eyodwa), ukuthwala isisindo ngemva kokuhlinzwa kwesitho esithintekile kuvunyelwe, ukubhuleka kwedolo kunganciphisa ukungakhululeki kwesiguli, kuye ngokuthi isiguli singakwazi yini ukuhamba ngesikhathi esifanele. Ukusekelwa kwe-contralateral ye-crutch eyodwa kunganciphisa ubuhlungu, kodwa ukusekelwa kwesikhathi eside kwezinduku akudingeki. Izitishi zasuswa emavikini ama-2 ngemuva kokuhlinzwa futhi i-Muenster noma i-long arm to thumb cast yagcinwa endaweni yayo amasonto ama-3. Ngemva kwalokho, kusetshenziswa i-short arm to thumb cast kuze kube yilapho i-fracture iphola. Ama-X-ray athathwa ngezikhathi zamaviki ama-3-6, futhi ukuphulukiswa kwe-fracture kuqinisekiswa yi-CT. Ngemuva kwalokho, imisebenzi esebenzayo neyokwenziwa kanye nokwandiswa kufanele iqalwe kancane kancane, futhi ukuqina kanye nokuvama kokuzivocavoca kufanele kwandiswe kancane kancane.
Izinkinga ezinkulu
Izinkinga eziyinhloko zejoyinti ledolo zifaka phakathi ubuhlungu bedolo noma ukulimala kwemizwa. Ubuhlungu bedolo buvele kakhulu zingakapheli amasonto ayi-6 ngemuva kokuhlinzwa, futhi akukho ukulahlekelwa kwezinzwa noma i-neuroma ebuhlungu ngenxa yokulimala kwemizwa okubangelwa yi-saphenous. Izinkinga eziyinhloko zesandla zazihlanganisa ukungahlangani kwamathambo angenakunyakaziswa, ubuhlungu, ukuqina kwamalunga, ubuthakathaka, i-osteoarthritis eqhubekayo yesandla se-radial noma amathambo e-intercarpal, kanye nengozi ye-periosteal heterotopic ossification nayo ibikiwe.
Ukufakelwa Kwamathambo Okuhlanganisiwe Kwamahhala Kwe-Medial Femoral Condyle Vascularised Bone kwama-Scaphoid Nonunions ane-Proximal Pole Avascular Necrosis kanye ne-Carpal Collapse
Isikhathi sokuthunyelwe: Meyi-28-2024
