Malunion navicular yana faruwa a kusan kashi 5-15% na dukkan karaya mai tsanani na kashin navicular, tare da necrosis na navicular yana faruwa a kusan 3%. Abubuwan haɗari don malunion navicular sun haɗa da rasa ko jinkirta ganewar asali, kusancin layin karaya, ƙaura fiye da 1 mm, da karaya tare da rashin kwanciyar hankali na carpal. Idan ba a kula da shi ba, navicular osteochondral nonunion yawanci yana hade da cututtukan cututtuka masu rauni, wanda kuma aka sani da navicular osteochondral nonunion tare da rushewar osteoarthritis.
Za'a iya amfani da dashen kashi tare da ko ba tare da ƙwanƙwasa ƙwanƙwasa ba don magance navicular osteochondral nonunion. Duk da haka, ga marasa lafiya tare da osteonecrosis na igiya na kusa da kasusuwa na navicular, sakamakon kasusuwa na kasusuwa ba tare da ƙwanƙwasawa ba ba su da dadi, kuma ƙwayar maganin kashi shine kawai 40% -67%. Sabanin haka, adadin waraka na kasusuwa tare da ɓangarorin jijiyoyi na iya zama sama da 88% -91%. Babban ɓangarorin kasusuwan kasusuwa na jijiyoyi a cikin aikin asibiti sun haɗa da 1,2-ICSRA-tipped distal radius flap, graft kashi + vascular bundle implant, palmar radius flap, free iliac flap with vascularised tip, and medial femoral condylar bone flap (MFC VBG), da dai sauransu Sakamakon gyaran kashi tare da ƙwanƙwasa jini yana da gamsarwa. MFC VBG na kyauta an nuna yana da tasiri wajen maganin karayar ruwa tare da rushewar metacarpal, kuma MFC VBG yana amfani da reshe na articular na jijiyar gwiwa da ke sauka a matsayin babban reshe na trophic. Idan aka kwatanta da sauran flaps, MFC VBG yana ba da isasshen goyon baya na tsari don mayar da siffar al'ada na kashin navicular, musamman ma a cikin osteochondrosis fracture na navicular tare da nakasar baya (Hoto 1). A cikin jiyya na osteochondral osteonecrosis navicular tare da ci gaba na carpal rushewa, 1,2-ICSRA-tipped distal radius flap an ruwaito cewa yana da kashi 40% kawai, yayin da MFC VBG yana da kashi 100%.
Hoto 1. Karyewar kashi na navicular tare da nakasar "baya baya", CT yana nuna karaya tsakanin kasusuwan navicular a wani kusurwa na kusan 90 °.
Shirye-shiryen riga-kafi
Bayan gwajin jiki na wuyan hannu da ya shafa, dole ne a yi nazarin hoto don tantance matakin rushewar wuyan hannu. Hotunan rediyo na fili suna da amfani don tabbatar da wurin da aka karye, matakin ƙaura, da kasancewar resorption ko sclerosis na ƙarshen karya. Ana amfani da hotuna na baya don tantance rugujewar wuyan hannu, rashin zaman lafiyar wuyan hannu (DISI) ta amfani da gyare-gyaren tsayin wuyan hannu (tsawo/nisa) na ≤1.52 ko kusurwar lunate radial fiye da 15°. MRI ko CT na iya taimakawa wajen gano rashin daidaituwa na kashin navicular ko osteonecrosis. Lateral radiographs ko oblique sagittal CT na navicular kashi tare da navicular kusurwa> 45 ° yana nuna gajarta na navicular kashi, wanda aka sani da "nakasu baya sunkuyar".MRI T1, T2 low sigina nuna necrosis na navicular kashi, amma MRI yana da. babu wata ma'ana a bayyane wajen tantance waraka daga karaya.
Alamomi da contraindications:
Navicular osteochondral nonunion tare da sunkuyar da nakasa baya da DISI; MRI nuna ischemic necrosis na navicular kashi, intraoperative loosening na yawon shakatawa da kuma lura da karye karye karshen navicular kashi ne har yanzu farin sclerotic kashi; gazawar gyaran kashi na farko ko dunƙule gyarawa na ciki yana buƙatar babban tsarin gyaran kashi na VGB (1cm3). preoperative ko intraoperative binciken osteoarthritis na radial carpal hadin gwiwa; idan gagarumin malunion navicular tare da rugujewar osteoarthritis ya faru, to ana iya buƙatar denervation na wuyan hannu, navicular osteotomy, fusion quadrangular, proximal carpal osteotomy, jimlar carpal fusion, da dai sauransu, za a iya buƙata; navicular malunion, proximal necrosis, amma tare da al'ada navicular kasusuwa ilimin halittar jiki (misali, mara maruƙa na navicular karaya tare da matalauta jini wadata ga kusa sandar); raguwa na malunion navicular ba tare da osteonecrosis ba. (1,2-ICSRA za a iya amfani da shi azaman madadin madaidaicin radius).
Aikata Anatomy
Ana ba da MFC VBG ta wasu ƙananan tasoshin trophoblastic na interosseous (ma'ana 30, 20-50), tare da mafi yawan wadatar jini a baya baya zuwa na tsakiya na mata (ma'ana 6.4), sannan na gaba (ma'ana 4.9) Hoto 2). Wadannan tasoshin trophoblastic galibi ana ba da su ne ta hanyar jijiya mai gangarowa (DGA) da / ko babbar jijiya ta tsakiya (SMGA), wanda shine reshe na jijiyoyin mata na sama wanda kuma ke haifar da articular, musculocutaneous, da / ko rassan jijiya saphenous. . DGA ya samo asali ne daga ƙwanƙwasa na femoral na sama da ke kusa da matsakaicin matsakaici na tsakiya na medial malleolus, ko kuma a nesa na 13.7 cm kusa da farfajiyar articular (10.5-17.5 cm), kuma kwanciyar hankali na reshe ya kasance 89% a cikin samfurori na cadaveric. (Hoto na 3). DGA ta samo asali ne daga jijiyar mace ta sama a 13.7 cm (10.5 cm-17.5 cm) kusa da tsaka-tsakin malleolus fissure ko kusa da farfajiyar articular, tare da samfurin cadaveric yana nuna 100% kwanciyar hankali da diamita na kimanin 0.78 mm. Saboda haka, ko dai DGA ko SMGA an yarda da su, kodayake tsohon ya fi dacewa da tibiae saboda tsayi da diamita na jirgin ruwa.
Hoto 2. Rarraba hudu na tasoshin MFC trophoblast tare da layin kwance tsakanin semitendinosus da ligament na tsakiya na tsakiya A, layin mafi girma na trochanter B, layin maɗaukakin sandar patella C, layin na baya meniscus D.
Hoto 3. MFC vascular anatomy: (A) Extraosseous rassan da MFC trophoblastic vascular anatomy, (B) Nisa daga tushen jijiyoyin jini daga layin haɗin gwiwa.
Samun damar tiyata
An sanya mai haƙuri a ƙarƙashin maganin sa barci na gaba ɗaya a cikin matsayi na baya, tare da sashin da ya shafa ya sanya shi a kan teburin tiyata na hannu. Gabaɗaya, ana ɗaukar kashin kashin mai ba da gudummawa daga ƙwanƙolin mata na ipsilateral na tsaka-tsaki, ta yadda mai haƙuri zai iya motsawa tare da kullun bayan tiyata. Hakanan za'a iya zaɓar gwiwa mai cin karo da juna idan akwai tarihin raunin da ya gabata ko tiyata a gefe ɗaya na gwiwa. Ƙwaƙwalwar gwiwa tana jujjuyawa kuma hip yana jujjuya waje, kuma ana amfani da yawon shakatawa a duka na sama da na ƙasa. Hanyar tiyata ita ce tsawaita tsarin Russe, tare da ƙaddamarwa ta fara 8 cm kusa da ramin carpal mai jujjuyawa kuma yana nisa daga gefen radial na radial flexor carpi radialis tendon, sa'an nan kuma nadawa a ramin carpal mai juyawa zuwa gindin babban yatsa. , yana ƙarewa a matakin mafi girma trochanter. An yanke kullin jijiya na jijiyar radial longissimus kuma an zana jijiyar ba tare da izini ba, kuma kashi na navicular yana fallasa ta hanyar rarrabuwa mai kaifi tare da radial lunate da radial na navicular head ligaments, tare da tsantsan rabuwa na gefe taushi kyallen takarda na navicular kashi don ba da damar. ƙarin bayyanar da kashi na navicular (Figure 4). Tabbatar da yankin rashin haɗin gwiwa, ingancin guringuntsi na articular da matakin ischemia na kashin navicular. Bayan sassauta yawon shakatawa, lura da sandar kusa da kashin navicular don zubar da jini don sanin ko akwai ischemic necrosis. Idan navicular necrosis ba a hade da radial carpal ko intercarpal arthritis, MFC VGB za a iya amfani da.
Hoto 4. Hanyar tiyata ta Navicular: (A) Ƙarƙashin yana farawa 8 cm kusa da rami na carpal mai jujjuya kuma ya shimfiɗa gefen radial na radial flexor carpi radialis tendon zuwa ga nisa na incision, wanda aka nannade zuwa gindin babban yatsan yatsa. a cikin rami na carpal transverse. (B) An yanka kullin jijiya na jijiyar radial longissimus kuma an zana jijiyar a hankali, kuma ƙashin navicular yana fallasa ta hanyar rarrabuwa mai kaifi tare da radial lunate da radial navicular head ligaments. (C) Gano wurin dakatarwar osseous na navicular.
An yi tsayin tsayin tsayin 15-20 cm kusa da layin haɗin gwiwa na gwiwa tare da iyaka na baya na tsokar mata ta tsakiya, kuma tsoka ta koma baya don fallasa samar da jini na MFC (Fig. 5) Ana ba da gudummawar jini na MFC gabaɗaya. ta rassan articular na DGA da SMGA, yawanci suna ɗaukar babban reshen haɗin gwiwa na DGA da madaidaicin jijiya. An saki pedicle na jijiyoyin jini a kusa, yana kula da kare periosteum da tasoshin trophoblastic akan saman kasusuwa.
Hoto 5. Samun damar yin amfani da tiyata zuwa MFC: (A) An yi tsayin daka na 15-20 cm kusa da iyakar baya na tsokar mata ta tsakiya daga layin haɗin gwiwa na gwiwa. (B) Ana janye tsoka a gaba don fallasa samar da jini na MFC.
Shiri na navicular kashi
Dole ne a gyara nakasar DISI na navicular kuma a shirya wurin daskararren kashin osteochondral kafin a dasa shi ta hanyar jujjuya wuyan hannu a ƙarƙashin fluoroscopy don dawo da kusurwar lunate na radial na al'ada (Hoto 6). Ƙafa 0.0625 (kimanin 1.5-mm) Kirschner fil ana hakowa a kai a kai daga dorsal zuwa metacarpal don gyara haɗin gwiwa na radial lunate, kuma ratar malunion na navicular yana fallasa lokacin da aka mike wuyan hannu. An share sararin karyewa daga nama mai laushi kuma an ƙara buɗe shi tare da shimfidar faranti. Ana amfani da ƙaramin zato mai maimaitawa don daidaita ƙashi kuma a tabbatar da cewa ƙwanƙwaran da aka dasa ya yi kama da tsarin rectangular fiye da ƙugiya, wanda ke buƙatar a sarrafa tazarar navicular tare da tazara mai faɗi a gefen dabino fiye da na dorsal. Bayan bude ratar, ana auna lahani a cikin nau'i uku don sanin girman kashin kashin, wanda yawanci shine 10-12 mm a tsayi a kowane bangare na dasa.
Hoto 6. Gyara nakasar baya na navicular, tare da jujjuyawar fluoroscopic na wuyan hannu don dawo da daidaitawar radial-lunar na al'ada. Ƙafa 0.0625 (kimanin 1.5-mm) Kirschner fil yana hakowa daga dorsal zuwa metacarpal don gyara haɗin gwiwa na radial lunate, yana fallasa ratar malunion navicular da kuma dawo da tsayin al'ada na navicular kashi lokacin da wuyan hannu ya mike, tare da girman girman. tazarar da ke hasashen girman maɗaurin da zai buƙaci a katse shi.
Osteotomy
An zaɓi yankin da aka lalatar da ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar cuta. Yi hankali kada ku cutar da ligament na tsakiya. An ƙaddamar da periosteum, kuma an yanke kasusuwan kashi rectangular girman girman girman da ake so tare da tsintsiya mai maimaitawa, tare da kashin kashi na biyu da aka yanke a 45 ° tare da gefe ɗaya don tabbatar da amincin kullun (Fig. 7). 7). Ya kamata a kula da kar a raba periosteum, kashin cortical, da soke kashi na kada. Ya kamata a saki yawon shakatawa na ƙasa don lura da yadda jini ke gudana ta cikin kullun, kuma ya kamata a saki pedicle na jijiyoyi a kusa don akalla 6 cm don ba da damar anastomosis na jijiyoyin jini na gaba. Idan ya cancanta, za a iya ci gaba da ɗan ƙaramin kashi mai sokewa a cikin kwandon mata. Cike da lahani na maƙarƙashiya na mata yana cike da maye gurbin kashi, kuma ana zubar da ƙashin ƙugu kuma a rufe shi ta hanyar layi.
Hoto 7. MFC kashin kasusuwa. (A) Yankin osteotomy wanda ya isa ya cika sararin ruwa yana da alama, an yanka periosteum, kuma an yanke kasusuwan kashi rectangular girman girman girman da ake so tare da tsintsiya mai juyawa. (B) An yanke kashi na biyu na kashi tare da gefe ɗaya a 45 ° don tabbatar da amincin kullun.
Tufafi da gyarawa
Ana gyara maƙarƙashiyar kashin zuwa siffar da ta dace, tare da kula da kada a danne jijiyar jijiyoyin jini ko tube periosteum. Ana dasa maƙarƙashiyar a hankali a cikin yanki na lahani na navicular, yana guje wa bugun, kuma a gyara shi da screws na navicular. An yi taka-tsantsan don tabbatar da cewa gefen dabino na toshewar kashin da aka dasa ya dunkule da gefen dabino na kashin navicular ko kuma ya dan yi sanyi don gudun kada ya taso. An yi fluoroscopy don tabbatar da yanayin kasusuwa na navicular, layin karfi da matsayi na dunƙule. Anastomose da jijiyoyin bugun jini zuwa radial artery karshen zuwa gefe da venous tip zuwa radial artery abokin jijiya karshen zuwa ƙarshe (Hoto 8). An gyara capsule na haɗin gwiwa, amma an guje wa pedicle na jijiyoyin jini.
Hoto 8. Ƙaƙwalwar kasusuwa na kasusuwa, gyarawa, da anastomosis na jijiyoyin jini. Ana dasa kashin kashin a hankali a cikin yanki na lahani na navicular kuma an gyara shi tare da screws na navicular mara kyau ko Kirschner fil. Ana kula da cewa gefen metacarpal na toshewar ƙashin da aka dasa yana juye tare da gefen metacarpal na ƙashin navicular ko kuma a hankali tawaya don guje wa tawaya. Anastomosis na jijiyoyin bugun jini na jijiyoyin bugun jini zuwa jijiyar radial an yi shi daga ƙarshe zuwa ƙarshe, kuma ƙarshen jijiya zuwa jijiya na radial artery an yi ta ƙarshe zuwa ƙarshe.
Gyaran bayan tiyata
Aspirin na baka 325 MG kowace rana (na wata 1), an ba da izinin ɗaukar nauyin abin da ya shafa bayan tiyata, birki na gwiwa zai iya rage rashin jin daɗi na majiyyaci, ya danganta da ikon majiyyaci na motsawa a daidai lokacin. Taimakon da ba a saba ba na kullun guda ɗaya zai iya rage ciwo, amma goyon bayan dogon lokaci na kullun ba lallai ba ne. An cire dinkin makonni 2 bayan tiyata kuma an ajiye Muenster ko dogon hannu zuwa simintin yatsan hannu na tsawon makonni 3. Bayan haka, ana amfani da gajeren hannu zuwa simintin yatsan yatsa har sai karaya ta warke. Ana ɗaukar hasken X-ray a tsakar mako 3-6, kuma CT ya tabbatar da waraka daga karaya. Bayan haka, ya kamata a fara aiki da sauye-sauye da ayyukan haɓakawa a hankali, kuma ƙarfin da yawan motsa jiki ya kamata a ƙara a hankali.
Manyan rikitarwa
Babban matsalolin haɗin gwiwa na gwiwa sun haɗa da ciwon gwiwa ko raunin jijiya. Ciwon gwiwa ya fi faruwa a cikin makonni 6 bayan tiyata, kuma ba a sami hasara na azanci ko neuroma mai raɗaɗi ba saboda raunin jijiya na saphenous. Babban rikice-rikicen wuyan hannu sun haɗa da rashin daidaituwa na kashi, zafi, taurin haɗin gwiwa, rauni, ci gaban osteoarthritis na radial wuyan hannu ko kasusuwan intercarpal, da kuma hadarin periosteal heterotopic ossification kuma an ruwaito.
Free Medial Femoral Condyle Vascularised Bone Grafting for Scaphoid Nonunions with Proximal Pole Avascular Necrosis and Carpal Collapse
Lokacin aikawa: Mayu-28-2024
