Indlela ye-suprapatellar iyindlela yokuhlinzwa eguquliwe yezinzipho ze-tibial intramedullary endaweni yedolo enwetshiwe kancane. Kunezinzuzo eziningi, kodwa futhi nokungalungi, ekwenzeni izinzipho ze-intramedullary ze-tibia ngendlela ye-suprapatellar endaweni ye-hallux valgus. Abanye odokotela abahlinzayo bajwayele ukusebenzisa i-SPN ukwelapha zonke izimfa ze-tibial ngaphandle kwezimfa ze-extra-articular ze-proximal 1/3 ye-tibia.
Izinkomba ze-SPN yilezi:
1. Ukuqhekeka kwesiqu se-tibial okuqhekekile noma okuhlukaniswe ngezigaba. 2;
2. ukuphuka kwe-distal tibial metaphysis;
3. ukuphuka kwesinqe noma idolo okunomkhawulo okhona wokugoba (isb., ijoyinti lesinqe eliwohlokayo noma ukuhlangana, i-osteoarthritis yedolo) noma ukungakwazi ukugoba idolo noma isinqe (isb., ukuhlukana kwesinqe ngemuva, ukuphuka kwe-ipsilateral femur);
4. ukuphuka kwe-tibial kuhlanganiswe nokulimala kwesikhumba ku-tendon ye-infrapatellar;
5. ukuphuka kwe-tibial esigulini esine-tibia ende kakhulu (ingxenye engezansi ye-tibia ivame ukuba nzima ukuyibona ngeso lengqondo ngaphansi kwe-fluoroscopy lapho ubude be-tibia budlula ubude be-tripod lapho i-fluoroscopy ingadlula khona).
Inzuzo yendlela yezinzipho ye-tibial intramedullary position semi-extended knee position ekwelapheni i-mid-tibial diaphysis kanye nokuqhekeka kwe-tibial distal itholakala ekubeni lula kokubeka kabusha indawo kanye nokuba lula kwe-fluoroscopy. Le ndlela ivumela ukusekelwa okuhle kakhulu kobude obugcwele be-tibia kanye nokunciphisa kalula i-sagittal kokuqhekeka ngaphandle kwesidingo sokuphathwa (Izithombe 1, 2). Lokhu kuqeda isidingo somsizi oqeqeshiwe ukusiza ngenqubo yezinzipho ye-intramedullary.
Isithombe 1: Indawo evamile yendlela yezinzipho zangaphakathi kwe-infrapatellar: idolo lisesimweni esigobile ku-tripod engenekayo nge-fluoroscopically. Kodwa-ke, lesi simo singakhulisa ukungalingani kahle kwe-fracture block futhi sidinga amasu engeziwe okunciphisa ukuqhekeka.
Umfanekiso 2: Ngokuphambene nalokho, isikhundla sedolo esandisiwe endaweni yokuma kwe-foam senza kube lula ukuhambisana kwe-fracture block kanye nokuphathwa okulandelayo.
Amasu Okuhlinzwa
Ithebula/Isikhundla Isiguli silele embhedeni we-fluoroscopic. Kungenziwa ukubambelela emilenzeni engezansi, kodwa akudingekile. Ithebula le-Vascular lifaneleka kahle ezinzipheni ze-suprapatellar approach tibial intramedullary, kodwa akudingekile. Kodwa-ke, imibhede eminingi yokubeka ama-fracture noma imibhede ye-fluoroscopic ayinconywa njengoba ingafaneleki ezinzipheni ze-suprapatellar approach tibial intramedullary.
Ukufaka ithanga eliseceleni kwe-ipsilateral kusiza ukugcina umkhawulo ongezansi usesimweni esijikelezwe ngaphandle. I-ramp ye-foam ehlanzekile isetshenziswa ukuphakamisa umlenze othintekile ngaphezu kohlangothi oluseceleni kwe-posterolateral fluoroscopy, kanti indawo yesinqe nedolo egobile nayo iyasiza ekuqondiseni indawo yezinzipho kanye ne-intramedullary. I-angle efanele yokugoba idolo isaphikiswana ngayo, lapho uBeltran et al. ephakamisa ukugoba idolo okungu-10° kanti uKubiak ephakamisa ukugoba idolo okungu-30°. Iningi lezazi liyavuma ukuthi ama-engeli okugoba idolo ngaphakathi kwalezi zigaba ayamukeleka.
Kodwa-ke, u-Eastman nabanye bathole ukuthi njengoba i-engeli yokugoba kwamadolo ikhuphuka kancane kancane isuka ku-10° kuya ku-50°, umphumela we-femoral talon ekungeneni kwensimbi ngendlela eqondile wehlisiwe. Ngakho-ke, i-engeli enkulu yokugoba kwamadolo izosiza ekukhetheni indawo efanele yokungena kwezipikili ngaphakathi kwe-medullary kanye nokulungisa ukukhubazeka kwe-angular endizeni ye-sagittal.
I-Fluoroscopy
Umshini wengalo ye-C kufanele ubekwe ohlangothini oluphambene lwetafula ukusuka esithweni esithintekile, futhi uma udokotela ohlinzayo emi ohlangothini lwedolo elithintekile, umshini wokuqapha kufanele ube sekhanda lomshini wengalo ye-C futhi useduze. Lokhu kuvumela udokotela ohlinzayo kanye nodokotela we-radiologist ukuthi babone kalula umshini wokuqapha, ngaphandle kwalapho kufanele kufakwe isipikili esixhumene kude. Nakuba kungaphoqelekile, ababhali batusa ukuthi ingalo ye-C ihanjiswe ohlangothini olufanayo kanye nodokotela ohlinzayo aye kolunye uhlangothi lapho kufanele kuqhutshwe isikulufu esixhumene phakathi. Ngaphandle kwalokho, umshini wengalo ye-C kufanele ubekwe ohlangothini oluthintekile ngenkathi udokotela ohlinzayo enza inqubo ohlangothini oluphambene (Isithombe 3). Lena yindlela evame ukusetshenziswa ababhali ngoba igwema isidingo sokuba udokotela ohlinzayo asuke ohlangothini oluphakathi aye ohlangothini olungaseceleni lapho eshayela isipikili esivalekayo kude.
Isithombe 3: Udokotela ohlinzayo umi ngakolunye uhlangothi lwe-tibia ethintekile ukuze isikulufu esixhumene naso siqhutshwe kalula. Isibonisi sibekwe maqondana nodokotela ohlinzayo, ekhanda lengalo ye-C.
Zonke izithombe ze-anteroposterior kanye ne-medial-lateral fluoroscopic zitholakala ngaphandle kokuhambisa isitho esithintekile. Lokhu kugwema ukufuduka kwendawo yokuqhekeka eseyilungisiwe ngaphambi kokuba ukuqhekeka kulungiswe ngokuphelele. Ngaphezu kwalokho, izithombe zobude obuphelele be-tibia zingatholakala ngaphandle kokutshekisa ingalo ye-C ngendlela echazwe ngenhla.
Ukusikwa kwesikhumba Kokubili ukusikwa okulinganiselwe nokunwetshiwe kahle kuyafaneleka. Indlela ye-percutaneous suprapatellar ye-intramedullary nail isekelwe ekusetshenzisweni kokusikwa okungu-3-cm ukushayela uzipho. Iningi lalezi zisikwa zokuhlinzwa zinde, kodwa zingaphinde zibe yi-transverse, njengoba kunconywe nguDkt. Morandi, kanti ukusikwa okunwetshiwe okusetshenziswe nguDkt. Tornetta nabanye kukhonjisiwe ezigulini ezine-combined patellar subluxation, ezinendlela ye-medial noma ye-lateral paratellar. Isithombe 4 sibonisa ukusikwa okuhlukile.
Umfanekiso 4: Umfanekiso wezindlela ezahlukene zokusikwa kokuhlinzwa.1- Indlela ye-Suprapatellar transpatellar ligament; 2- Indlela ye-Parapatellar ligament; 3- Indlela ye-Medial limited incision parapatellar ligament; 4- Indlela ye-Medial ended incision parapatellar ligament; 5- Indlela ye-lateral parapatellar ligament. Ukuvezwa okujulile kwendlela ye-parapatellar ligament kungaba ngejoyinti noma ngaphandle kwe-joint bursa.
Ukuvezwa okujulile
Indlela ye-percutaneous suprapatellar yenziwa ngokuyinhloko ngokuhlukanisa i-tendon ye-quadriceps ngobude kuze kube yilapho isikhala singakwazi ukwamukela ukudlula kwezinsimbi ezifana nezipikili zangaphakathi. Indlela ye-parapatellar ligament, edlula eduze kwemisipha ye-quadriceps, ingase iboniswe futhi endleleni yezipikili zangaphakathi kwe-tibial. Inaliti ye-trocar e-blunt kanye ne-cannula kudluliswa ngokucophelela nge-patellofemoral joint, inqubo eqondisa ngokuyinhloko indawo yokungena engaphambili-ephakeme ye-tibial intramedullary nail ngokusebenzisa i-femoral trocar. Uma i-trocar isibekwe kahle, kumele iboshwe endaweni yayo ukuze kugwenywe ukulimala kwe-articular cartilage yedolo.
Indlela enkulu yokusikwa kwe-transligamentous ingasetshenziswa kanye ne-hyperextension parapatellar skin incision, ngendlela ye-medial noma ye-lateral. Nakuba abanye odokotela abahlinzayo bengaligcini i-bursa ingaphelele ngesikhathi sokuhlinzwa, uKubiak nabanye bakholelwa ukuthi i-bursa kufanele igcinwe ingaphelele futhi izakhiwo ezingaphandle kwe-articular kufanele zivele ngokwanele. Ngokwethiyori, lokhu kunikeza isivikelo esihle kakhulu sejoyinti ledolo futhi kuvimbela umonakalo onjengokutheleleka kwedolo.
Indlela echazwe ngenhla ihlanganisa nokuhlukaniswa kwe-patella nge-hemi-dislocation, okunciphisa ingcindezi yokuxhumana ezindaweni ezihlangene ngezinga elithile. Uma kunzima ukwenza ukuhlolwa kwamalunga e-patellofemoral nge-cavity encane yamalunga kanye nedivayisi yokwandisa idolo elinganiselwe kakhulu, abalobi batusa ukuthi i-patella ingahlukaniswa kancane ngokuhlukaniswa kwamalunga. Ngakolunye uhlangothi, ukusikwa okuphambene okuphakathi kugwema ukulimala kwamalunga asekelayo, kodwa kunzima ukwenza ukulungiswa kokulimala kwedolo okuphumelelayo.
Indawo yokungena kwenaliti ye-SPN ifana neyokusebenzisa i-infrapatellar. I-fluoroscopy yangaphambili neyaseceleni ngesikhathi sokufakwa kwenaliti iqinisekisa ukuthi indawo yokufakwa kwenaliti ilungile. Udokotela ohlinzayo kumele aqinisekise ukuthi inaliti eqondisayo ayidonselwa kude kakhulu ngemuva iye ku-proximal tibia. Uma idonselwa ngokujulile ngemuva, kufanele ibekwe kabusha ngosizo lwesipikili esivimbayo ngaphansi kwe-posterior coronal fluoroscopy. Ngaphezu kwalokho, u-Eastman nabanye bakholelwa ukuthi ukubhoboza iphini lokungena endaweni yedolo egobile kakhulu kusiza ekushintsheni kokuphuka okulandelayo endaweni enwetshiwe.
Amathuluzi okunciphisa
Amathuluzi awusizo okunciphisa afaka phakathi ama-forceps okunciphisa amaphuzu anobukhulu obuhlukene, ama-femoral lifters, amadivayisi okuqinisa angaphandle, kanye nama-fixator angaphakathi okuqinisa izingcezu ezincane zokuphuka nge-cortical plate eyodwa. Izipikili ezivimbayo zingasetshenziswa futhi enkambisweni yokunciphisa okukhulunywe ngayo ngenhla. Ama-reduction hammers asetshenziselwa ukulungisa i-sagittal angulation kanye nokukhubazeka kokufuduka okuphambene.
Izimila
Abakhiqizi abaningi be-orthopedic internal fixators bathuthukise izinhlelo zokusebenzisa izinsimbi ukuqondisa ukufakwa okujwayelekile kwezinzipho ze-tibial intramedullary. Kuhlanganisa ingalo ende yokuma, idivayisi yokulinganisa ubude bephini eqondiswayo, kanye ne-medullary expander. Kubaluleke kakhulu ukuthi izinzipho ze-trocar kanye ne-blunt trocar zivikele kahle ukufinyelela kwezinzipho ze-intramedullary. Udokotela ohlinzayo kumele aqinisekise kabusha indawo ye-cannula ukuze ukulimala kwejoyinti le-patellofemoral noma izakhiwo ze-periarticular ngenxa yokusondela kakhulu kudivayisi yokushayela.
Izikulufu Zokukhiya
Udokotela ohlinzayo kumele aqinisekise ukuthi kufakwa inani elanele lezikulufo zokukhiya ukuze kulondolozwe ukuncipha okwanelisayo. Ukulungiswa kwezingcezu ezincane zokuqhekeka (eziseduze noma ezikude) kwenziwa ngezikulufo zokukhiya ezintathu noma ngaphezulu phakathi kwezingcezu zokuqhekeka eziseduze, noma ngezikulufo ezine-angle eqondile zodwa. Indlela ye-suprapatellar yobuchwepheshe bezinzipho ze-tibial intramedullary ifana nendlela ye-infrapatellar ngokwendlela yokushayela izikulufo. Izikulufo zokukhiya ziqhutshwa ngokunembe kakhudlwana ngaphansi kwe-fluoroscopy.
Ukuvalwa kwenxeba
Ukumunca nge-casing yangaphandle efanele ngesikhathi sokuvuleka kususa izingcezu zamathambo ezikhululekile. Wonke amanxeba adinga ukuniselwa kahle, ikakhulukazi indawo yokuhlinzwa edolweni. I-tendon noma i-ligament layer kanye ne-suture endaweni yokuqhekeka kuyavalwa, kulandelwe ukuvalwa kwe-dermis nesikhumba.
Ukususwa kozipho lwe-intramedullary
Ukuthi isipikili se-tibial intramedullary esiqhutshwa ngendlela ye-suprapatellar singasuswa ngendlela ehlukile yokuhlinzwa kusalokhu kuyimpikiswano. Indlela evame kakhulu yindlela ye-transarticular suprapatellar yokususwa kwezipikili ze-intramedullary. Le ndlela iveza isipikili ngokubhoboza ngesiteshi sezipikili se-suprapatellar intramedullary kusetshenziswa i-drill engenalutho engu-5.5 mm. Ithuluzi lokususa izipikili libe seliqhutshwa ngesiteshi, kodwa lokhu kungaba nzima. Izindlela ze-parapatellar kanye ne-infrapatellar ziyizindlela ezihlukile zokususa izipikili ze-intramedullary.
Izingozi Izingozi zokuhlinzwa zendlela ye-suprapatellar yendlela yezinzipho ze-tibial intramedullary ukulimala kwezokwelapha ku-patella kanye ne-femoral talus cartilage, ukulimala kwezokwelapha kwezinye izakhiwo zangaphakathi kwe-articular, ukutheleleka kwamalunga, kanye nokungcola kwangaphakathi kwe-articular. Kodwa-ke, kukhona ukuntuleka kwemibiko yamacala omtholampilo ehambisanayo. Iziguli ezine-chondromalacia zizothambekela kakhulu ekulimaleni kwe-cartilage okubangelwa ukwelashwa. Ukulimala kwezokwelapha ezakhiweni zangaphandle ze-patellar kanye ne-femoral articular kuyinto ekhathaza kakhulu odokotela abahlinzayo abasebenzisa le ndlela yokuhlinzwa, ikakhulukazi indlela ye-transarticular.
Kuze kube manje, abukho ubufakazi bezokwelapha obukhona mayelana nezinzuzo kanye nokungalungi kwendlela yezinzipho ye-semi-extension tibial intramedullary.
Isikhathi sokuthunyelwe: Okthoba-23-2023
