Indlela ye-suprapatellar iyindlela yokuhlinzwa eguquliwe ye-tibial intramedullary nail endaweni yedolo enwetshiwe.Kunezinzuzo eziningi, kodwa futhi nokubi, ukwenza isipikili se-intramedullary ye-tibia ngendlela ye-suprapatellar endaweni ye-hallux valgus.Abanye odokotela abahlinzayo bajwayele ukusebenzisa i-SPN ukuphatha zonke izinhlobo ze-tibial fractures ngaphandle kwe-extra-articular fractures ye-proximal 1/3 ye-tibia.
Izinkomba ze-SPN yilezi:
1. Ukuqhekeka okwenziwe noma okuyingxenye yesiqu se-tibial.2;
2. ukuphuka kwe-distal tibial metaphysis;
3. ukuphuka kwe-hip noma idolo ngokukhawulwa kwangaphambili kokuguquguquka (isb, ukuhlanganiswa kwe-hip okuwohlokayo noma ukuhlanganiswa, i-osteoarthritis yamadolo) noma ukungakwazi ukuguquguquka idolo noma i-hip (isb. i-femur);
4. ukuphuka kwe-tibial kuhlangene nokulimala kwesikhumba ku-tendon ye-infrapatellar;
5. ukuphuka kwe-tibial esigulini esine-tibia ende kakhulu (ukuphela okuseduze kwe-tibia ngokuvamile kunzima ukukubona ngeso lengqondo ngaphansi kwe-fluoroscopy lapho ubude be-tibia budlula ubude be-tripod lapho i-fluoroscopy ingadlula khona).
Inzuzo ye-semi-extended knee position tibial intramedullary nail technique yokwelashwa kwe-mid-tibial diaphysis kanye ne-distal tibial fractures ilele ekululameni kokubeka kabusha kanye nokulula kwe-fluoroscopy.Le ndlela ivumela ukusekelwa okuhle kakhulu kobude obugcwele be-tibia kanye nokunciphisa i-sagittal elula yokuphuka ngaphandle kwesidingo sokukhwabanisa (Izibalo 1, 2).Lokhu kuqeda isidingo somsizi oqeqeshiwe ukuze asize ngesu le-intramedullary nail.
Umfanekiso 1: Isimo esijwayelekile sesu le-intramedullary nail lendlela ye-infrapatellar: idolo lisesimweni esigobile ku-tripod engena nge-fluoroscopically.Kodwa-ke, lesi sikhundla singakhulisa ukuqondana okungalungile kwebhulokhi yokuphuka futhi kudinga amasu okunciphisa engeziwe okunciphisa ukuphuka.
Umfanekiso 2: Ngokuphambene, ukuma kwedolo elinwetshiwe kurempu yegwebu kusiza ukuqondanisa kwebhulokhi yokuphuka kanye nokukhohlisa okulandelayo.
Amasu Okuhlinzwa
Ithebula / Isikhundla Isiguli silala endaweni ephansi phezu kombhede we-fluoroscopic.I-traction ephansi ingenziwa, kodwa akudingekile.Ithebula le-Vascular lifaneleka kahle indlela ye-suprapatellar ye-tibial intramedullary nail, kodwa akudingekile.Kodwa-ke, imibhede eminingi yokubeka i-fracture noma imibhede ye-fluoroscopic ayinconywa njengoba ingafaneleki ku-suprapatellar approach tibial intramedullary nail.
Ukuphehla ithanga le-ipsilateral kusiza ukugcina umkhawulo ongezansi usendaweni ezungezelwe ngaphandle.Irempu yegwebu eliyinyumba ibese isetshenziselwe ukuphakamisa isitho esithintekile ngaphezu kohlangothi lwe-contralateral lwe-posterolateral fluoroscopy, futhi indawo egobile ye-hip nedolo nayo iyasiza ekuqondiseni uphini kanye nokubeka izinzipho ngaphakathi kwe-intramedullary.I-engeli ye-knee flexion elungile isaphikisana, no-Beltran et al.iphakamisa ukugoba kwedolo okungu-10° bese u-Kubiak ephakamisa ukugoba kwedolo okungu-30°.Iningi lezazi liyavuma ukuthi ama-engeli e-knee flexion ngaphakathi kwalezi zigaba ayamukeleka.
Nokho, u-Eastman et al.ithole ukuthi njengoba i-knee flexion angle yanda kancane kancane ukusuka ku-10 ° kuya ku-50 °, umphumela we-femoral talon ekungeneni kwe-percutaneous kwensimbi wancishiswa.Ngakho-ke, i-knee flexion angle enkulu izosiza ekukhetheni indawo efanele yokungena kwe-intramedullary nail ukulungisa ukukhubazeka kwe-angular endizeni ye-sagittal.
I-Fluoroscopy
Umshini we-C-arm kufanele ubekwe ngakolunye uhlangothi lwetafula kusukela esithweni esithintekile, futhi uma udokotela ohlinzayo emi eceleni kwedolo elithintekile, umqaphi kufanele abe sekhanda lomshini we-C-arm futhi asondele eduze. .Lokhu kuvumela udokotela ohlinzayo kanye ne-radiologist ukuthi abone kalula i-monitor, ngaphandle kwalapho kuzofakwa isikhonkwane se-distal interlocking.Nakuba kungeyona impoqo, ababhali batusa ukuthi i-C-arm ihanjiswe ohlangothini olufanayo futhi udokotela ohlinzayo aye kolunye uhlangothi lapho isikulufu esixhumanisa esiphakathi sizoqhutshwa.Ngaphandle kwalokho, umshini we-C-arm kufanele ubekwe ohlangothini oluthintekile ngenkathi udokotela ohlinzayo enza inqubo ohlangothini lwe-contralateral (Umfanekiso 3).Lena indlela evame ukusetshenziswa kakhulu ngababhali ngoba igwema isidingo sokuthi udokotela ohlinzayo asuke ohlangothini oluphakathi ukuya ohlangothini olungemuva lapho eshayela isikhonkwane sokukhiya i-distal.
Umfanekiso wesi-3: Udokotela ohlinzayo umi ngakolunye uhlangothi lwe-tibia ethintekile ukuze isikulufu sokuxhuma esiphakathi singaqhutshwa kalula.Isibonisi sitholakala ngokuphambene nodokotela ohlinzayo, ekhanda le-C-arm.
Konke ukubukwa kwe-anteroposterior kanye ne-medial-lateral fluoroscopic kutholakala ngaphandle kokunyakazisa isitho esithintekile.Lokhu kugwema ukugudluzwa kwesayithi lokuphuka esethwe kabusha ngaphambi kokuthi ukuphuka kulungiswe ngokuphelele.Ngaphezu kwalokho, izithombe zobude obugcwele be-tibia zingatholakala ngaphandle kokutshekisa i-C-arm ngendlela echazwe ngenhla.
Ukusikwa kwesikhumba Kokubili ukusika okulinganiselwe futhi okunwetshiwe kufanelekile.Indlela ye-percutaneous suprapatellar ye-intramedullary nail isekelwe ekusetshenzisweni kwe-3-cm yokusika ukushayelela isipikili.Iningi lalezi zimbobo zokuhlinzwa ziyi-longitudinal, kodwa zingaphinde ziguquke, njengoba kunconywe uDkt. Morandi, futhi ukusika okunwetshiwe okusetshenziswe uDkt Tornetta nabanye kuboniswa ezigulini ezine-patellar subluxation ehlangene, ene-parapatellar ephakathi nendawo noma ehlangothini. sondela.Umdwebo 4 ubonisa ukusika okuhlukile.
Umfanekiso wesi-4: Umfanekiso wezindlela ezihlukene zokuhlinza zokuhlinzwa.1- Indlela ye-Suprapatellar transpatellar ligament;I-2- Parapatellar ligament approach;3- Indlela ye-parapatellar ligament elinganiselwe emaphakathi;I-4- Indlela yokusika i-parapatellar ligament ephakathi;5- I-Lateral parapatellar ligament approach.Ukuvezwa okujulile kwendlela ye-parapatellar ligament kungaba ngokuhlanganyela noma ngaphandle kwe-joint bursa.
Ukuchayeka okujulile
Indlela ye-percutaneous suprapatellar yenziwa ngokuyinhloko ngokuhlukanisa ubude be-tendon ye-quadriceps kuze kube yilapho igebe likwazi ukwamukela ukudlula kwezinsimbi ezifana nezinzipho ze-intramedullary.Indlela ye-parapatellar ligament, edlula eduze kwe-quadriceps muscle, ingase futhi iboniswe ku-tibial intramedullary nail technique.Inaliti ye-trocar e-blunt kanye ne-cannula idluliswa ngokucophelela ngokuhlanganyela kwe-patellofemoral, inqubo eqondisa ngokuyinhloko indawo yokungena yangaphambili-phezulu ye-tibial intramedullary nail ngokusebenzisa i-trocar ye-femoral.Uma i-trocar ibekwe kahle, kufanele ivikelwe endaweni ukuze igweme ukulimala ku-articular cartilage yamadolo.
Indlela enkulu yokusika i-transligamentous ingasetshenziswa ngokuhambisana nokusika kwesikhumba se-hyperextension parapatellar, ngendlela ephakathi noma ehlangothini.Nakuba abanye odokotela abahlinzayo bengayilondolozi i-bursa injalo ngokuhlinza, u-Kubiak et al.bakholelwa ukuthi i-bursa kufanele igcinwe iphelele futhi izakhiwo ezingaphezulu kwe-articular kufanele zivezwe ngokwanele.Ngokweqile, lokhu kunikeza isivikelo esihle kakhulu sokuhlangana kwamadolo futhi kuvimbela ukulimala okufana nokutheleleka kwamadolo.
Indlela echazwe ngenhla iphinde ihlanganise i-hemi-dislocation ye-patella, okunciphisa ukucindezela kokuxhumana ezindaweni ze-articular ngezinga elithile.Uma kunzima ukwenza ukuhlolwa okuhlangene kwe-patellofemoral nge-cavity encane ehlangene kanye nedivayisi enwetshiwe kakhulu yamadolo, abalobi batusa ukuthi i-patella ingahlukaniswa kancane ngokuhlukaniswa kwe-ligament.I-median transverse incision, ngakolunye uhlangothi, igwema ukulimala emithanjeni esekelayo, kodwa kunzima ukwenza ukulungiswa okuphumelelayo kokulimala kwamadolo.
Indawo yokungena yenaliti ye-SPN iyafana naleyo yendlela ye-infrapatellar.I-fluoroscopy yangaphambili nengemuva ngesikhathi sokufakwa kwenaliti iqinisekisa ukuthi indawo yokufaka inaliti ilungile.Udokotela ohlinzayo kufanele aqinisekise ukuthi inaliti eqondisayo ayiqhutshwa kude kakhulu ngemuva kwe-tibia eseduze.Uma ishayelwa ngokujulile ngemuva, kufanele ibekwe kabusha ngosizo lwe-nail evimbelayo ngaphansi kwe-posterior coronal fluoroscopy.Ngaphezu kwalokho, u-Eastman et al.kholelwa ukuthi ukubhoboza iphinikhodi yokungena endaweni ephinyisiwe eguquguqukayo yamadolo kusiza ekumiseni kabusha kokuphuka okulandelayo endaweni enwetshiwe.
Amathuluzi okunciphisa
Amathuluzi asebenzayo okunciphisa ahlanganisa ama-forcep okunciphisa amaphuzu osayizi abahlukahlukene, iziphakamisi ze-femoral, izinto zokulungisa zangaphandle, nezilungisi zangaphakathi zokulungiswa kwezingcezu ezincane zokuphuka nge-cortical plate eyodwa.Izipikili zokuvimbela nazo zingasetshenziselwa inqubo yokunciphisa eshiwo ngenhla.Izando zokunciphisa zisetshenziselwa ukulungisa i-angulation ye-sagittal kanye nokukhubazeka okugudluzayo.
Izimila
Abakhiqizi abaningi be-fixator yangaphakathi ye-orthopedic baye bahlakulela izinhlelo zokusebenzisa izinsimbi zokuqondisa ukubekwa okujwayelekile kwezipikili ze-tibial intramedullary.Kubandakanya ingalo yokuma enwetshiwe, idivayisi yokulinganisa ubude bephinikhodi, kanye nesinwebi se-medullary.Kubaluleke kakhulu ukuthi i-trocar ne-blunt trocar pins ivikele ukufinyelela kwe-intramedullary nail kahle.Udokotela ohlinzayo kufanele aphinde aqinisekise isikhundla se-cannula ukuze ukulimala kwe-patellofemoral joint noma izakhiwo ze-periarticular ngenxa yokusondelana kakhulu nedivayisi yokushayela kungenzeki.
Izikulufo zokukhiya
Udokotela ohlinzayo kufanele aqinisekise ukuthi inombolo eyanele yezikulufu zokukhiya zifakiwe ukuze kugcinwe ukuncipha okwanelisayo.Ukulungiswa kwezingcezu ezincane zokuphuka (eziseduze noma ezikude) kufezwa ngezikulufu zokukhiya ezingu-3 noma ngaphezulu phakathi kwezingcezu zokuphuka eziseduze, noma ngezikulufu ze-engeli engaguquki zodwa.Indlela ye-suprapatellar ye-tibial intramedullary nail technique ifana nendlela ye-infrapatellar mayelana nenqubo yokushayela isikulufa.Izikulufu zokukhiya zishayelwa ngokunembe kakhulu ngaphansi kwe-fluoroscopy.
Ukuvalwa kwamanxeba
Ukumunca ngegodi langaphandle elifanelekile ngesikhathi sokunwetshwa kususa izingcezu zamathambo zamahhala.Wonke amanxeba adinga ukuchelelwa kahle, ikakhulukazi indawo yokuhlinza amadolo.Ithenda ye-quadriceps noma isendlalelo se-ligament kanye ne-suture esizeni sokuphuka kuyavalwa, kulandelwa ukuvalwa kwedermis nesikhumba.
Ukususwa kwe-intramedullary nail
Ukuthi i-tibial intramedullary nail eshayelwa ngendlela ye-suprapatellar ingasuswa ngendlela yokuhlinzwa ehlukile ihlala iyimpikiswano.Indlela evame kakhulu iyindlela ye-transarticular suprapatellar yokususa izinzipho ze-intramedullary.Le nqubo iveza isikhonkwane ngokubhoboza isiteshi sezinzipho se-suprapatellar intramedullary kusetshenziswa umgodi ongenalutho ongu-5.5 mm.Ithuluzi lokususa izinzipho libe seliqhutshwa ngesiteshi, kodwa lokhu kuqondisa kungase kube nzima.Izindlela ze-parapatellar kanye ne-infrapatellar ezinye izindlela zokususa izipikili ze-intramedullary.
Izingozi Izingozi zokuhlinzwa zendlela ye-suprapatellar ye-tibial intramedullary nail technique ukulimala kwezokwelapha ku-patella kanye ne-femoral talus cartilage, ukulimala kwezokwelapha kwezinye izakhiwo ze-intra-articular, ukutheleleka okuhlangene, kanye nemfucumfucu ye-intra-articular.Nokho, kukhona ukuntuleka kwemibiko yecala lomtholampilo elihambisanayo.Iziguli ezine-chondromalacia zizoba sengozini yokulimala kwe-cartilage eyenziwe ngokwemithi.Ukulimala kwezokwelapha ku-patellar kanye ne-femoral articular surface structures kuyinkinga enkulu kodokotela abahlinzayo abasebenzisa le ndlela yokuhlinzwa, ikakhulukazi indlela ye-transarticular.
Kuze kube manje, abukho ubufakazi bomtholampilo bezibalo mayelana nezinzuzo kanye nokubi kwe-semi-extension tibial intramedullary nail technique.
Isikhathi sokuthumela: Oct-23-2023
