Malunion na Navicular yana faruwa a cikin kusan kashi 5-15% na dukkan karyewar ƙashi mai tsanani na ƙashin navicular, tare da necrosis na navicular yana faruwa a cikin kusan kashi 3%. Abubuwan da ke haifar da malunion na navicular sun haɗa da rashin ganewa ko jinkiri, kusancin layin karyewar kusa, ƙaura fiye da 1 mm, da karyewar tare da rashin kwanciyar hankali na carpal. Idan ba a yi magani ba, rashin daidaituwar osteochondral navicular galibi ana danganta shi da cututtukan amosanin gabbai, wanda kuma aka sani da navicular osteochondral nonion tare da rushewar osteoarthritis.
Ana iya amfani da dashen ƙashi tare da ko ba tare da lap ɗin vascularized ba don magance matsalar osteochondral na navicular nonunion. Duk da haka, ga marasa lafiya da ke fama da osteonecrosis na sandar kusa ta ƙashin navicular, sakamakon dashen ƙashi ba tare da lap ɗin vascular ba shi da kyau, kuma ƙimar warkar da ƙashi shine 40%-67% kawai. Sabanin haka, ƙimar warkar da dashen ƙashi tare da lap ɗin vascularized na iya kaiwa har zuwa 88%-91%. Manyan lap ɗin vascularized a aikin asibiti sun haɗa da lap ɗin distal radius mai kusurwa 1,2-ICSRA, dashen ƙashi + dashen vascular bundle, lap ɗin palmar radius, lap ɗin iliac mai kusurwa vascularized, da lap ɗin medial femoral condylar bone flap (MFC VBG), da sauransu. Sakamakon dashen ƙashi tare da lap ɗin vascularized sun gamsar. An nuna cewa MFC VBG kyauta yana da tasiri wajen magance karyewar navicular tare da rugujewar metacarpal, kuma MFC VBG yana amfani da reshen articular na jijiyar gwiwa da ke saukowa a matsayin babban reshe na trophic. Idan aka kwatanta da sauran laɓɓai, MFC VBG yana ba da isasshen tallafi na tsari don dawo da siffar ƙashin navicular daidai, musamman a cikin karyewar navicular osteochondrosis tare da nakasar baya mai lanƙwasa (Hoto na 1). A cikin maganin osteonecrosis navicular osteochondral tare da rushewar carpal mai ci gaba, an ruwaito cewa laɓɓar radius mai kusurwa 1,2-ICSRA tana da ƙimar warkar da ƙashi na 40% kawai, yayin da MFC VBG tana da ƙimar warkar da ƙashi na 100%.
Hoto na 1. Karyewar ƙashin navicular tare da nakasar "sunkuyar baya", CT yana nuna toshewar karyewa tsakanin ƙasusuwan navicular a kusurwar kusan 90°.
Shirye-shiryen kafin tiyata
Bayan gwajin jiki na wuyan hannu da abin ya shafa, dole ne a yi nazarin hotuna don tantance matakin rugujewar wuyan hannu. Hotunan rediyo marasa motsi suna da amfani don tabbatar da wurin da karayar ta faru, matakin ƙaura, da kuma kasancewar resorption ko sclerosis na ƙarshen da ya karye. Ana amfani da hotunan gaba na baya don tantance rugujewar wuyan hannu, rashin kwanciyar hankali na wuyan hannu (DISI) ta amfani da rabon tsayin wuyan hannu da aka gyara (tsawo/faɗi) na ≤1.52 ko kusurwar lunate mai radial fiye da 15°. MRI ko CT na iya taimakawa wajen gano rashin daidaituwar ƙashin navicular ko osteonecrosis. Hotunan rediyo na gefe ko CT mai lanƙwasa na sagittal na ƙashin navicular tare da kusurwar navicular sama da 45° yana nuna gajarta ƙashin navicular, wanda aka sani da "nakasar baya mai lanƙwasa". Alamar ƙarancin MRI T1, T2 tana nuna necrosis na ƙashin navicular, amma MRI ba shi da wata ma'ana a bayyane wajen tantance warkar da karayar.
Alamomi da contraindications:
Navicular osteochondral nonunion tare da nakasar baya mai lanƙwasa da DISI; MRI yana nuna ischemic necrosis na ƙashin navicular, sassauta tourniquet a lokacin tiyata da kuma lura da karyewar ƙarshen ƙashin navicular har yanzu yana da farin ƙashin sclerotic; gazawar farkon dasa ƙashin wedge ko gyara ciki yana buƙatar babban dasa ƙashin tsarin VGB (＞1cm3). Binciken osteoarthritis na haɗin radial carpal kafin tiyata ko a lokacin tiyata; idan an sami babban malunion navicular tare da rushewar osteoarthritis, to ana iya buƙatar rage wuyan hannu, osteotomy navicular, haɗin quadrangular, osteotomy na carpal proximal, haɗin carpal gaba ɗaya, da sauransu; malunion navicular, necrosis na proximal, amma tare da yanayin ƙashin navicular na yau da kullun (misali, karyewar navicular mara motsi tare da ƙarancin jini zuwa sandar proximal); rage malunion navicular ba tare da osteonecrosis ba. (1,2-ICSRA za a iya amfani da shi azaman madadin madaidaicin radius flap).
Tsarin Halittar Jiki
Ana samar da MFC VBG ta hanyar wasu ƙananan tasoshin trophoblastic interosseous (matsakaicin 30, 20-50), inda mafi yawan jinin da ke cikin jini ya kasance ƙasa da na medial femoral condyle (matsakaicin 6.4), sai kuma na gaba (matsakaicin 4.9) (Hoto na 2). Waɗannan tasoshin trophoblastic galibi ana samar da su ne ta hanyar jijiyar geniculate (DGA) da/ko babban jijiyoyin geniculate medial (SMGA), wanda reshe ne na jijiyar femoral sama wadda kuma ke haifar da rassan jijiyoyi na articular, musculocutaneous, da/ko saphenous. DGA ta samo asali ne daga jijiyar femoral sama kusa da tsakiyar tsakiyar malleolus, ko kuma a nesa na 13.7 cm kusa da saman articular (10.5-17.5 cm), kuma kwanciyar hankalin reshe ya kasance 89% a cikin samfuran cadaveric (Hoto na 3). DGA ya samo asali ne daga jijiyar femoral mai tsayin 13.7 cm (10.5 cm-17.5 cm) kusa da fissure na medial malleolus ko kuma kusa da saman articular, tare da samfurin cadaveric wanda ke nuna daidaiton rassan 100% da diamita na kusan 0.78 mm. Saboda haka, ko dai DGA ko SMGA abin karɓa ne, kodayake na farko ya fi dacewa da tibiae saboda tsayi da diamita na jirgin.
Hoto na 2. Rarraba tasoshin trophoblast na MFC mai kusurwa huɗu tare da layin kwance tsakanin semitendinosus da ligament na tsakiya na A, layin babban trochanter B, layin sandar sama ta patella C, layin meniscus na gaba D.
Hoto na 3. Tsarin Jijiyoyin Jijiyoyin MFC: (A) Rassa masu ƙarfi da tsarin Jijiyoyin Jijiyoyin MFC trophoblastic, (B) Nisa daga asalin jijiyoyin jini daga layin haɗin gwiwa
Samun damar tiyata
Ana sanya majiyyaci a ƙarƙashin maganin sa barci na gaba ɗaya a kan kujera, tare da sanya hannun da abin ya shafa a kan teburin tiyatar hannu. Gabaɗaya, ana ɗaukar laɓɓan ƙashin mai bayarwa daga tsakiyar cinyar ... An yanke murfin jijiyar radial longissimus sannan a ja jijiyar a hankali, sannan kuma kashi navicular ya bayyana ta hanyar yankewa mai kaifi tare da jijiyoyin radial lunate da radial navicular head, tare da raba kyallen laushi na gefe na kashi navicular don ba da damar ƙarin fallasa ƙashin navicular (Hoto na 4). Tabbatar da yankin da ba a haɗa shi ba, ingancin guringuntsi na articular da matakin ischaemia na ƙashin navicular. Bayan sassauta tourniquet, lura da sandar kusa ta ƙashin navicular don zubar jini mai zurfi don tantance ko akwai ischaemic necrosis. Idan navicular necrosis ba shi da alaƙa da radial carpal ko intercarpal arthritis, ana iya amfani da MFC VGB.
Hoto na 4. Hanyar tiyata ta Navicular: (A) An yanke shi daga nesa da santimita 8 kusa da ramin carpal mai wucewa kuma ya shimfiɗa gefen radial na radial flexor carpi radialis tendon zuwa ɓangaren nesa na yankewar, wanda aka naɗe zuwa ƙasan babban yatsa a ramin carpal mai wucewa. (B) An yanke murfin jijiyar radial longissimus jijiyar kuma an ja jijiyar a hankali, kuma ƙashin navicular yana bayyana ta hanyar yankewa mai kaifi tare da jijiyoyin radial lunate da radial navicular head. (C) Gano yankin da aka daina ci gaba da navicular osseous.
An yi yanke mai tsawon santimita 15-20 kusa da layin haɗin gwiwa na gwiwa tare da iyakar baya na tsokar femoral ta tsakiya, sannan a ja tsokar a gaba don fallasa kwararar jinin MFC (Hoto na 5). Yawancin lokaci ana samar da wadatar jinin MFC ta hanyar rassan articular na DGA da SMGA, yawanci ana ɗaukar babban reshen haɗin gwiwa na DGA da jijiyar da ke tare da ita. Ana sakin ƙafar jijiyoyin jini kusa da juna, yana mai da hankali kan kare periosteum da tasoshin trophoblastic a saman ƙashi.
Hoto na 5. Hanyar tiyata zuwa MFC: (A) An yi yanke mai tsawon santimita 15-20 kusa da gefen bayan tsokar femoral ta tsakiya daga layin haɗin gwiwa. (B) An ja tsokar a gaba don fallasa kwararar jinin MFC.
Shiri na ƙashin navicular
Dole ne a gyara nakasar navicular DISI sannan a shirya yankin dashen ƙashi na osteochondral kafin a dasa shi ta hanyar lanƙwasa wuyan hannu a ƙarƙashin fluoroscopy don dawo da kusurwar lunate ta al'ada (Hoto na 6). Ana haƙa fil ɗin Kirschner mai tsawon ƙafa 0.0625 (kimanin 1.5-mm) daga dorsal zuwa metacarpal don daidaita haɗin lunate na radial, kuma ana fallasa gibin malunion navicular lokacin da aka miƙe wuyan hannu. An cire sararin karyewar daga nama mai laushi kuma an ƙara buɗe shi da mai shimfiɗa faranti. Ana amfani da ƙaramin zarto mai juyawa don daidaita ƙashin kuma a tabbatar da cewa lanƙwasa dashen ya yi kama da tsari mai kusurwa huɗu fiye da wedge, wanda ke buƙatar a sarrafa gibin navicular da babban gibi a gefen palmar fiye da gefen dorsal. Bayan buɗe gibin, ana auna lahani a girma uku don tantance girman dashen ƙashi, wanda yawanci tsawonsa shine 10-12 mm a duk bangarorin dashen.
Hoto na 6. Gyaran nakasar baya da aka lankwasa ta navicular, tare da lankwasawar wuyan hannu mai fluoroscopic don dawo da daidaiton radial-lunar na yau da kullun. An haƙa ramin Kirschner mai tsawon ƙafa 0.0625 (kimanin 1.5-mm) daga baya zuwa ga metacarpal don gyara haɗin radial lunate, yana fallasa gibin malunion na navicular da kuma dawo da tsayin da ya dace na ƙashin navicular lokacin da aka miƙe wuyan hannu, tare da girman gibin yana hasashen girman lap ɗin da zai buƙaci a katse.
Ciwon ƙashi (osteotomy)
An zaɓi yankin da aka yi wa jijiyoyin jini na tsakiyar femoral condyle alama a matsayin yankin cire ƙashi, kuma an yi wa yankin cire ƙashi alama yadda ya kamata. A yi hankali kada a ji wa jijiyoyin tsakiya rauni. An yanke periosteum, sannan a yanke wani kashin mai kusurwa huɗu mai girman da ya dace da lanƙwasa da ake so da zaren da aka so da zaren da aka yi masa, tare da yanke wani toshe na ƙashi na biyu a 45° a gefe ɗaya don tabbatar da ingancin lanƙwasa (Hoto na 7). 7). Ya kamata a yi taka tsantsan kada a raba periosteum, ƙashin cortical, da ƙashin cancellous na lanƙwasa. Ya kamata a saki tourniquet na ƙasan gaɓɓai don lura da yadda jini ke gudana ta lanƙwasa, kuma a saki ƙashin jijiyoyin kusa da aƙalla 6 cm don ba da damar samun nakasa ta jijiyoyin jini na gaba. Idan ya cancanta, ana iya ci gaba da ƙaramin ƙashin cancellous a cikin lanƙwasa ta femoral. Ana cika lahani na lanƙwasa ta femoral da madadin dashen ƙashi, kuma ana zubar da yankewar kuma a rufe ta lanƙwasa ta lanƙwasa.
Hoto na 7. Cire murfin ƙashi na MFC. (A) An yi wa yankin osteotomy alama don cike sararin navicular, an yanke periosteum, sannan a yanke murfin ƙashi mai kusurwa huɗu mai girman da ya dace da murfin da ake so da zaren da ake so da zaren da ke juyawa. (B) An yanke wani yanki na ƙashi na biyu a gefe ɗaya a 45° don tabbatar da ingancin murfin.
Dasawa da gyara flap
Ana gyara murfin ƙashi zuwa siffar da ta dace, ana kula da kada a matse ƙwallon jijiyoyin jini ko a cire periosteum. Ana sanya murfin a hankali a yankin da ke da lahani ga ƙashin navicular, ana guje wa bugun jini, sannan a gyara shi da sukurori masu ramuka. An yi taka-tsantsan don tabbatar da cewa gefen palmar na ɓangaren ƙashin da aka dasa ya yi daidai da gefen palmar na ƙashin navicular ko kuma an ɗan rage shi kaɗan don guje wa haɗuwa. An yi amfani da fluoroscopy don tabbatar da yanayin ƙashin navicular, layin ƙarfi da matsayin sukurori. An cire jijiyar flap na jijiyoyin jini zuwa ƙarshen jijiyar radial zuwa gefe da kuma ƙarshen venous zuwa ƙarshen venous na radial jijiyar abokin tarayya (Hoto na 8). Ana gyara haɗin gwiwar capsule, amma ana guje wa pedicle na jijiyoyin jini.
Hoto na 8. Dasa ƙashi, gyarawa, da kuma cire ƙashi daga ƙashi. Ana sanya ƙashin a hankali a yankin da ke da lahani a ƙashin navicular kuma a gyara shi da sukurori masu rami ko fil ɗin Kirschner. Ana kulawa cewa gefen metacarpal na toshe ƙashin da aka dasa ya yi daidai da gefen metacarpal na ƙashin navicular ko kuma a ɗan rage shi kaɗan don guje wa lalacewa. An yi aikin cire ƙashin jijiyar jijiyoyin jini zuwa ga jijiyar radial daga ƙarshe zuwa ƙarshe, kuma an yi aikin cire ƙashin jijiyar zuwa ga jijiyar radial daga abokin aikin jijiyar radial daga ƙarshe zuwa ƙarshe.
Gyaran jiki bayan tiyata
Aspirin da ake sha 325 MG a kowace rana (na tsawon wata 1), bayan tiyata, an yarda a ɗauki nauyin gaɓɓan da abin ya shafa, birki a gwiwa zai iya rage rashin jin daɗin majiyyaci, ya danganta da ikon majiyyacin na motsawa a lokacin da ya dace. Tallafin madauri ɗaya na gefe na iya rage zafi, amma ba lallai ba ne a ɗauki dogon lokaci na sandunan. An cire ɗinkin bayan makonni 2 bayan tiyata kuma an ajiye Muenster ko dogon hannu zuwa babban yatsa na tsawon makonni 3. Bayan haka, ana amfani da gajeren hannu zuwa babban yatsa har sai karayar ta warke. Ana ɗaukar hotunan X-ray a tazara tsakanin makonni 3-6, kuma CT ta tabbatar da warkarwar karyewa. Bayan haka, ya kamata a fara ayyukan lanƙwasawa da faɗaɗawa a hankali, kuma ya kamata a ƙara ƙarfi da yawan motsa jiki a hankali.
Manyan matsaloli
Manyan matsalolin da ke tattare da haɗin gwiwa sun haɗa da ciwon gwiwa ko raunin jijiya. Ciwon gwiwa ya fi faruwa ne cikin makonni 6 bayan tiyata, kuma ba a sami asarar ji ko ciwon jijiya mai zafi ba sakamakon raunin jijiya mai rauni. Manyan matsalolin wuyan hannu sun haɗa da rashin haɗin ƙashi mai ƙarfi, ciwo, taurin gaɓoɓi, rauni, ciwon osteoarthritis mai ci gaba na wuyan hannu ko ƙasusuwan intercarpal, da kuma haɗarin kamuwa da cututtukan heterotopic na periosteal.
Rarraba Kashi na Tsakiyar Femoral Condyle na Jijiyoyin Jini Kyauta don Rarraba Kashi na Scaphoid tare da Necrosis na Jijiyoyin Jini da Rushewar Carpal
Lokacin Saƙo: Mayu-28-2024
