I-malunion ye-Navicular yenzeka cishe ku-5-15% yakho konke ukuphuka okukhulu kwethambo le-navicular, ne-necrosis ye-navicular eyenzeka cishe ku-3%. Izici eziyingozi ze-malunion ye-navicular zihlanganisa ukuxilongwa okuphuthelwe noma okubambezelekile, ukusondelana komugqa wokuphuka, ukufuduka okukhulu kuno-1 mm, nokuphuka ngokungazinzi kwe-carpal. Uma ishiywe ingalashwa, i-osteochondral nonunion ye-navicular ivame ukuhlotshaniswa nesifo samathambo esibuhlungu, eyaziwa nangokuthi i-navicular osteochondral nonunion ne-osteoarthritis ewayo.
Ukuxhunyelelwa kwethambo nge-flap ene-vascularised noma ngaphandle kwayo kungasetshenziswa ukwelapha i-navicular osteochondral nonunion. Kodwa-ke, ezigulini ezine-osteonecrosis ye-proximal pole ye-navicular bone, imiphumela yokuhlanganiswa kwethambo ngaphandle kwe-vascular tip ayigculisi, futhi izinga lokuphulukisa amathambo lingama-40% -67 kuphela%. Ngokuphambene, izinga lokuphulukisa lokuxhunyelelwa kwamathambo ane-vascularised flaps lingaba phezulu ku-88% -91%. Ukuvuleka kwamathambo amakhulu anemithambo yegazi ekusebenzeni komtholampilo kufaka phakathi i-1,2-ICSRA-tipped distal flap, i-bone graft + i-vascular bundle implant, i-palmar radius flap, i-flap yamahhala yethambo le-iliac enethiphu ye-vascularised, kanye ne-medial femoral condylar bone flap (MFC VBG), njll. Imiphumela yokuxhunyelelwa kwethambo nge-tip ye-vascularised iyanelisa. I-MFC VBG yamahhala iboniswe ukuthi iyasebenza ekwelapheni ukuphuka kwe-navicular ngokuwa kwe-metacarpal, futhi i-MFC VBG isebenzisa igatsha le-articular lomthambo wedolo owehla njengegatsha eliyinhloko le-trophic. Uma kuqhathaniswa namanye ama-flap, i-MFC VBG inikeza ukwesekwa kwesakhiwo okwanele ukubuyisela isimo esivamile sethambo le-navicular, ikakhulukazi ku-navicular fracture osteochondrosis enokukhubazeka okugobile emuva (Umfanekiso 1). Ekwelapheni i-navicular osteochondral osteonecrosis ngokuwohloka kwe-carpal okuqhubekayo, i-distal flap enetiphu engu-1,2-ICSRA kubikwe ukuthi inezinga lokuphulukiswa kwethambo elingu-40% kuphela, kuyilapho i-MFC VBG inezinga lokuphulukiswa kwethambo elingu-100%.
Umfanekiso 1. Ukuphuka kwethambo le-navicular elinokukhubazeka "okugobile," i-CT ibonisa ukuphuka phakathi kwamathambo e-navicular nge-engeli engaba ngu-90 °.
Ukulungiselela ngaphambi kokuhlinzwa
Ngemuva kokuhlolwa ngokomzimba kwesihlakala esithintekile, izifundo zokuthwebula kufanele zenziwe ukuze kuhlolwe izinga lokuwa kwesihlakala. Ama-radiographs angenalutho awusizo ukuqinisekisa indawo yokuphuka, izinga lokufuduka, kanye nokuba khona kwe-resorption noma i-sclerosis yesiphetho esiphukile. Izithombe ezingemuva zangaphambili zisetshenziselwa ukuhlola ukugoqeka kwengalo, ukuntengantenga komgogodla wesandla (DISI) kusetshenziswa isilinganiso esishintshiwe sobude besihlakala (ubude/ububanzi) obungu-≤1.52 noma i-engeli yenyanga eyiradial engaphezu kuka-15°. I-MRI noma i-CT ingasiza ekuhloleni ukungahambi kahle kwethambo le-navicular noma i-osteonecrosis. I-radiographs yangemuva noma i-oblique sagittal CT yethambo le-navicular ene-navicular angle>45° iphakamisa ukufinyezwa kwethambo le-navicular, elaziwa ngokuthi "ukukhubazeka okugobile".I-MRI T1, isignali ephansi ye-T2 iphakamisa i-necrosis yethambo le-navicular, kodwa i-MRI ine akukho ukubaluleka okusobala ekunqumeni ukuphulukiswa kokuphuka.
Izinkomba kanye contraindications:
I-Navicular osteochondral nonunion ene-back back deformity kanye ne-DISI; I-MRI ibonisa i-ischemic necrosis yethambo le-navicular, ukuxegiswa kwe-intraoperative ye-tourniquet kanye nokubona ukuphuka kwe-fracture ekupheleni kwethambo le-navicular kusese-white sclerotic bone; ukwehluleka kokuxhunyelelwa kokuqala kwethambo le-wedge noma ukulungiswa kwangaphakathi kwesikulufa kudinga ukuxhunyelelwa kwethambo lesakhiwo esikhulu se-VGB (＞1cm3). ukutholwa kwangaphambi kokuhlinzwa noma kwe-intraoperative ye-osteoarthritis ye-radial carpal joint; uma i-malunion ye-navicular ephawulekayo ene-osteoarthritis ewayo yenzekile, khona-ke ukuguqulwa kwesihlakala, i-navicular osteotomy, i-quadrangular fusion, i-proximal carpal osteotomy, ingqikithi ye-carpal fusion, njll., ingadingeka; i-malunion ye-navicular, i-proximal necrosis, kodwa ene-navicular bone morphology evamile (isb, ukuphuka kwe-navicular okungasuswanga nokunikezwa kwegazi eliphansi esigxotsheni esiseduze); ukufinyezwa kwe-malunion ye-navicular ngaphandle kwe-osteonecrosis. (I-1,2-ICSRA ingasetshenziswa esikhundleni se-distal radius flap).
I-Anatomy Esetshenziswayo
I-MFC VBG ihlinzekwa ngenani lemikhumbi ye-trophoblastic encane ye-interterosseous (isho i-30, i-20-50), negazi eliningi kakhulu lingaphansi kwe-condyle ye-femoral ephakathi (isho i-6.4), ilandelwa yi-anteriorly superior (isho i-4.9) ( Umfanekiso 2). Le mikhumbi ye-trophoblastic yayihlinzekwa ikakhulukazi umthambo we-geniculate (DGA) owehlayo kanye/noma umthambo ophezulu we-geniculate medial (SMGA), okuyigatsha lomthambo we-femoral ongaphezulu obuye ubangele amagatsha e-articular, musculocutaneous, kanye/noma noma ama-saphenous nerve. . I-DGA isuka emthanjeni we-femoral ongaphezulu kuya ekuphakameni okuphakathi kwe-malleolus ephakathi, noma ebangeni elingu-13.7 cm eliseduze nendawo ye-articular (10.5-17.5 cm), futhi ukuzinza kwe-branching kwakungama-89% kuma-cadaveric specimens. (Umfanekiso 3). I-DGA isuka emthanjeni we-femoral ongaphezulu ku-13.7 cm (10.5 cm-17.5 cm) eseduze ne-medial malleolus fissure noma esondele endaweni ye-articular, ne-specimen ye-cadaveric ebonisa ukuzinza kwe-branch engu-100% kanye nobubanzi obungaba ngu-0.78 mm. Ngakho-ke, i-DGA noma i-SMGA iyamukeleka, nakuba eyokuqala ifaneleka kakhulu i-tibiae ngenxa yobude nobubanzi bomkhumbi.
Umfanekiso 2. Ukusabalalisa kwama-quadrant amane wemikhumbi ye-MFC trophoblast eduze komugqa ovundlile phakathi kwe-semitendinosus kanye ne-medial collateral ligament A, umugqa we-trochanter enkulu B, umugqa we-pole ephakeme we-patella C, umugqa we-meniscus D wangaphambili.
Umfanekiso 3. I-MFC vascular anatomy: (A) Amagatsha e-Extraosseous kanye ne-MFC trophoblastic vascular anatomy, (B) Ibanga lemvelaphi ye-vascular kusukela kulayini ohlangene
Ukufinyelela ngokuhlinzwa
Isiguli sibekwe ngaphansi kwe-anesthesia ejwayelekile endaweni ye-supine, isitho esithintekile sibekwe etafuleni lokuhlinzwa kwesandla. Ngokuvamile, i-flap bone ye-donor ithathwa ku-condyle ye-femoral ye-ipsilateral medial, ukuze isiguli sikwazi ukuhamba ngezinduku ngemva kokuhlinzwa. Idolo eliphikisanayo lingabuye likhethwe uma kunomlando wokuhlukumezeka kwangaphambilini noma ukuhlinzwa ohlangothini olufanayo lwamadolo. Idolo liyaguquguquka futhi i-hip ijikeleziswa ngaphandle, futhi ama-tourniquets asetshenziswa kokubili phezulu nangaphansi. Indlela yokuhlinza yayiyindlela eyandisiwe yaseRusse, lapho ukusika kuqala ngo-8 cm eduze nomhubhe we-carpal onqamulayo futhi kunwebeka kude ukusuka onqenqemeni lwe-radial flexor carpi radialis tendon, bese kugoqa emhubheni we-carpal ophambanayo ukuya phansi kwesithupha. , egcina ezingeni le-trochanter enkulu. I-tendon sheath ye-radial longissimus tendon ifakwe futhi i-tendon idonswa ngokungahambi kahle, futhi ithambo le-navicular livezwa ukuhlukaniswa okubukhali eduze kwe-radial lunate kanye ne-radial navicular head ligaments, ngokuhlukaniswa ngokucophelela kwezicubu ezithambile ze-peripheral zethambo le-navicular ukuvumela. ukuvezwa okwengeziwe kwethambo le-navicular (Umfanekiso 4). Qinisekisa indawo ye-nonnunion, ikhwalithi ye-articular cartilage kanye nezinga le-ischemia yethambo le-navicular. Ngemva kokukhulula i-tourniquet, bheka isigxobo esiseduze sethambo le-navicular ukuze uthole ukopha kwe-punctate ukuze unqume ukuthi kukhona yini i-ischemic necrosis. Uma i-navicular necrosis ingahlotshaniswa ne-radial carpal noma i-intercarpal arthritis, i-MFC VGB ingasetshenziswa.
Umfanekiso 4. Indlela yokuhlinza i-Navicular: (A) Ukusika kuqala ngo-8 cm ukusondela emhubheni we-carpal onqamulayo futhi kunwebe unqenqema lwe-radial flexor carpi radialis tendon engxenyeni ekude ye-incision, egoqwe ibheke phansi kwesithupha. emhubheni we-carpal onqamulayo. (B) I-tendon sheath ye-radial longissimus tendon iyasikwa futhi i-tendon idwetshwa ulnarly, futhi ithambo le-navicular livezwa ngokuhlakazeka okubukhali eduze kwe-radial lunate kanye ne-radial head ligaments. (C) Khomba indawo ye-navicular osseous discontinuity.
Ukusika okungu-15-20 cm ubude kwenziwa eduze komugqa ohlangene wamadolo eduze komngcele ongemuva we-femoral muscle ephakathi, futhi umsipha uhlehliswa ngaphambili ukuze uveze ukunikezwa kwegazi kwe-MFC (Fig. 5) .Ukunikezwa kwegazi kwe-MFC ngokuvamile kunikezwa ngamagatsha aqondile we-DGA kanye ne-SMGA, ngokuvamile athatha igatsha elihlangene elikhulu le-DGA kanye nomthambo ohambisana nawo. I-vascular pedicle ikhululiwe eduze, inakekela ukuvikela i-periosteum kanye nemikhumbi ye-trophoblastic ebusweni be-bony.
Umfanekiso 5. Ukufinyelela ngokuhlinzwa ku-MFC: (A) Ukusika okungu-15-20 cm ubude kwenziwa eduze komngcele ongemuva wesiphakeli se-femoral esiphakathi ukusuka emugqeni ohlangene wamadolo. (B) Umsipha uhlehliswa ngaphambili ukuze uveze ukunikezwa kwegazi kwe-MFC..
Ukulungiswa kwethambo le-navicular
Ukukhubazeka kwe-DISI ye-navicular kufanele kulungiswe futhi indawo ye-osteochondral bone graft ilungiswe ngaphambi kokufakwa ngokugoba isihlakala ngaphansi kwe-fluoroscopy ukuze kubuyiselwe i-engeli evamile ye-radial lunate (Umfanekiso 6). Iphinikhodi ye-Kirschner engu-0.0625-foot (cishe u-1.5-mm) ibholwa nge-percutaneously ukusuka emhlane kuya ku-metacarpal ukuze kulungiswe ilunga le-radial lunate, futhi igebe le-malunion le-navicular liyavela lapho isihlakala siqondiswa. Isikhala sokuphuka sasuswa izicubu ezithambile futhi saphinde savulwa ngesipredishithi sepuleti. Isaha elincane elibuyiselanayo lisetshenziselwa ukwenza isicaba ithambo futhi kuqinisekiswe ukuthi i-flap yokufaka ifana kakhulu nesakhiwo esingunxande kune-wedge, okudinga ukuthi igebe le-navicular lisingathwe ngegebe elibanzi ohlangothini lwesundu kunasemhlane. Ngemva kokuvula igebe, ukukhubazeka kukalwa ngezilinganiso ezintathu ukuze kunqunywe izinga lokuxhunyelelwa kwamathambo, okuvamise ukuba ngu-10-12 mm ubude kuzo zonke izinhlangothi ze-graft.
Umfanekiso 6. Ukulungiswa kokukhubazeka okugobile kwe-navicular, ngokuguquguquka kwe-fluoroscopic kwengalo ukubuyisela ukuqondanisa kwe-radial-lunar okuvamile. Iphinikhodi ye-Kirschner engu-0.0625-foot (cishe u-1.5-mm) ibholwa ngokulinganayo ukusuka emhlane kuya ku-metacarpal ukuze kulungiswe ilunga le-radial lunate, okuveza igebe le-malunion ye-navicular nokubuyisela ukuphakama okuvamile kwethambo lokuzulazula lapho isihlakala siqondiswa, enosayizi we-malunion. igebe elibikezela usayizi we-flap ozodinga ukuvinjwa.
I-Osteotomy
Indawo ye-vascularised ye-condyle ye-femoral medial ikhethwa njengendawo yokukhishwa kwamathambo, futhi indawo yokukhishwa kwethambo imakwe ngokwanele. Qaphela ukuthi ungalimazi i-medial collateral ligament. I-periosteum ihlanjululwe, futhi i-rectangular bone flap yesayizi efanelekile ye-flap oyifunayo inqunywe nge-saw ephindaphindiwe, ne-bone block block yesibili enqunywe ku-45 ° ohlangothini olulodwa ukuze kuqinisekiswe ubuqotho be-flap (Fig. 7). 7). Ukunakekelwa kufanele kuthathwe ukuze kungahlukanisi i-periosteum, i-cortical bone, nethambo elikhansela le-flap. I-tourniquet yomkhawulo ophansi kufanele ikhishwe ukuze kubhekwe ukugeleza kwegazi nge-flap, futhi i-vascular pedicle kufanele ikhululwe cishe okungenani ama-6 cm ukuvumela i-anastomosis ye-vascular elandelayo. Uma kunesidingo, inani elincane lethambo elikhansela lingaqhutshekwa ngaphakathi kwe-condyle yesifazane. Isici se-femoral condylar sigcwaliswa esikhundleni se-bone graft, futhi ukusika kuyakhishwa futhi kuvalwe ungqimba ngongqimba.
Umfanekiso 7. Ukususwa kwe-bone flap ye-MFC. (A) Indawo ye-osteotomy eyanele ukugcwalisa isikhala se-navicular imakwe, i-periosteum iyasikwa, futhi i-flap yethambo elingunxande losayizi ofanele we-flap oyifunayo kusikwa ngesaha eliphindaphindayo. (B) Ucezu lwesibili lwethambo lusikwa ohlangothini olulodwa ku-45 ° ukuze kuqinisekiswe ubuqotho be-flap.
Ukufakwa kwe-Flap nokulungiswa
I-flap yamathambo inqunywe ukuze ibe nesimo esifanele, iqikelela ukuthi ingacindezeli i-vascular pedicle noma ihlubule i-periosteum. I-flap ifakwe kahle endaweni yethambo le-navicular, igwema ukushaywa, futhi ihlanganiswe nezikulufu ze-navicular ezingenalutho. Kwathathwa ukunakekelwa ukuze kuqinisekiswe ukuthi imajini yentende yebhulokhi yethambo etshaliwe ibigubha ngomkhawulo wentende yethambo le-navicular noma ukuthi ibicindezelwe kancane ukuze kugwenywe ukugxambukela. I-Fluoroscopy yenziwa ukuze kuqinisekiswe i-navicular bone morphology, umugqa wamandla kanye nokuma kwesikulufu. I-Anastomose i-vascular flap artery eya emthonjeni we-radial ekupheleni ukuya ohlangothini kanye nethiphu ye-venous ukuya kumthambo ohambisana ne-radial ohambisana nomthambo ekugcineni ekupheleni (Umfanekiso 8). I-capsule ehlangene iyalungiswa, kodwa i-vascular pedicle iyagwenywa.
Umfanekiso 8. Ukufakelwa kwe-flap yethambo, ukulungiswa, kanye ne-vascular anastomosis. I-bone flap ifakwe ngobumnene endaweni ye-navicular bone defect futhi ihlanganiswe nezikulufu ze-navicular ezingenalutho noma izikhonkwane ze-Kirschner. Kuyaqapheleka ukuthi imajini ye-metacarpal yebhulokhi yethambo efakiwe iguquguquka nemajini ye-metacarpal yethambo le-navicular noma icindezeleke kancane ukuze igweme ukuzifaka. I-anastomosis ye-vascular flap artery emthanjeni we-radial yenziwa ekugcineni kuze kube sekupheleni, futhi ithiphu le-vein emthanjeni ohambisana nomthambo we-radial wenziwa ekugcineni ukuya ekugcineni.
Ukuvuselelwa kwangemva kokuhlinzwa
I-aspirin yomlomo engu-325 mg ngosuku (inyanga engu-1), ukuthwala isisindo ngemuva kokuhlinzwa kwesitho esithintekile kuvunyelwe, ukubhuleka kwamadolo kunganciphisa ukungaphatheki kahle kwesiguli, kuye ngokuthi isiguli singakwazi ukunyakaza ngesikhathi esifanele. Ukwesekwa kwe-contralateral kwe-crutch eyodwa kunganciphisa ubuhlungu, kodwa ukusekelwa kwesikhathi eside kwezinduku akudingekile. Imithungo yakhishwa emavikini ama-2 ngemva kokuhlinzwa futhi i-Muenster noma ukhonkolo ende kuya kwesithupha kwagcinwa endaweni amasonto amathathu. Ngemuva kwalokho, ingalo emfishane ukuya kusithupha isetshenziswa kuze kube yilapho ukuphuka kuphola. Ama-X-ray athathwa ngezikhathi zamaviki angu-3-6, futhi ukuphulukiswa kokuphuka kuqinisekiswa yi-CT. Ngemva kwalokho, ukuguquguquka okusebenzayo nokungenzi lutho kanye nemisebenzi yokwandisa kufanele kuqalwe kancane kancane, futhi ukuqina kanye nemvamisa yokuzivocavoca kufanele kwandiswe kancane kancane.
Izinkinga ezinkulu
Izinkinga eziyinhloko zejoyinti lamadolo zihlanganisa ubuhlungu bamadolo noma ukulimala kwenzwa. Ubuhlungu bedolo ikakhulukazi benzeke phakathi kwamaviki e-6 ngemva kokuhlinzwa, futhi akukho ukulahlekelwa kwezinzwa noma i-neuroma ebuhlungu ngenxa yokulimala kwenzwa ye-saphenous etholakele. Izinkinga eziyinhloko zesihlakala zazihlanganisa ukungezwani kwethambo eliphikisayo, ubuhlungu, ukuqina kwamalunga, ubuthakathaka, i-osteoarthritis eqhubekayo yesihlakala se-radial noma amathambo e-intercarpal, kanye nengozi ye-periosteal heterotopic ossification nayo ibikiwe.
Ukuxhunyelelwa Kwethambo Kwamahhala Kwe-Femoral Condyle Vascularized for Scaphoid Nonunions nge-Proximal Pole Avascular Necrosis kanye neCarpal Collapse
Isikhathi sokuthumela: May-28-2024
