Hanyar suprapatellar wata hanya ce ta tiyata da aka gyara don ƙusa ta tibial intramedullary a cikin matsayin gwiwa mai tsayi. Akwai fa'idodi da yawa, amma kuma rashin amfani, don yin ƙusa ta intramedullary ta tibia ta hanyar hanyar suprapatellar a cikin matsayin hallux valgus. Wasu likitocin tiyata sun saba da amfani da SPN don magance duk karyewar tibial sai dai karyewar extra-articular na proximal 1/3 na tibia.
Alamomin SPN sune:
1. Karyewar ƙashi ko sassa na tushen tibial. 2;
2. karyewar ɓangaren metaphysis na tibial na nesa;
3. karyewar kwatangwalo ko gwiwa tare da ƙarancin lanƙwasawa (misali, lalacewar haɗin gwiwa ko haɗuwa, osteoarthritis na gwiwa) ko rashin iya lanƙwasa gwiwa ko kwatangwalo (misali, karyewar kwatangwalo na baya, karyewar ƙafar ƙafa ta baya);
4. karyewar tibial tare da raunin fata a jijiyar infrapatellar;
5. karyewar tibial a cikin majiyyaci mai tsayin tibi (ƙarshen tibial sau da yawa yana da wuya a iya gani a ƙarƙashin fluoroscopy lokacin da tsawon tibial ya wuce tsawon tripod wanda fluoroscopy zai iya wucewa).
Amfanin dabarar ƙusa ta tibial intramedullary mai matsakaicin tsayin gwiwa don magance cututtukan tsakiyar tibial da kuma karyewar tibial ta nesa yana cikin sauƙin sake saitawa da kuma sauƙin amfani da fluoroscopy. Wannan hanyar tana ba da damar tallafawa cikakken tsawon tibia da kuma rage karyewar sagittal ba tare da buƙatar yin amfani da shi ba (Hoto na 1, 2). Wannan yana kawar da buƙatar mataimaki mai horo don taimakawa da dabarar ƙusa ta intramedullary.
Hoto na 1: Matsayi na yau da kullun na dabarar ƙusa ta intramedullary don hanyar infrapatellar: gwiwa tana cikin matsayi mai lankwasawa akan tripod mai shiga cikin fluoroscopic. Duk da haka, wannan matsayi na iya ƙara ta'azzara rashin daidaito na toshewar karyewa kuma yana buƙatar ƙarin dabarun ragewa don rage karyewa.
Hoto na 2: Sabanin haka, tsawaitar gwiwa a kan hanyar kumfa tana sauƙaƙa daidaita tubalin karyewa da kuma yin amfani da shi daga baya.
Dabaru na Tiyata
Tebur / Matsayi Majinyaci yana kwance a kwance a kan gadon fluoroscopic. Ana iya yin jan ƙafar ƙasa, amma ba lallai ba ne. Teburin jijiyoyin jini ya dace da ƙusa ta tibial intramedullary ta suprapatellar, amma ba lallai ba ne. Duk da haka, ba a ba da shawarar yawancin gadajen da ke daidaita karyewa ko gadajen fluoroscopic ba saboda ba su dace da ƙusa ta tibial intramedullary ta suprapatellar ba.
Cire cinyar da ke gefen dama yana taimakawa wajen kiyaye ƙananan gefen dama a cikin yanayin juyawa na waje. Sannan ana amfani da wani tsari mai tsabta na kumfa don ɗaga gaɓoɓin da abin ya shafa sama da gefen da ke gefen dama don yin gwajin fluoroscopy na posterolateral, kuma matsayin kwatangwalo da gwiwa mai lanƙwasa yana taimakawa wajen jagorantar sanya ƙusa da kuma sanya ƙusa a cikin medullary. Har yanzu ana ta muhawara kan mafi kyawun kusurwar lanƙwasa gwiwa, inda Beltran da abokan aikinsa suka ba da shawarar lanƙwasa gwiwa 10°, kuma Kubiak ya ba da shawarar lanƙwasa gwiwa 30°. Yawancin malamai sun yarda cewa kusurwoyin lanƙwasa gwiwa a cikin waɗannan wurare abin karɓa ne.
Duk da haka, Eastman da abokan aikinsa sun gano cewa yayin da aka ƙara kusurwar lanƙwasa gwiwa a hankali daga 10° zuwa 50°, tasirin talon femoral akan shigar da kayan aikin a cikin fata ya ragu. Saboda haka, babban kusurwar lanƙwasa gwiwa zai taimaka wajen zaɓar madaidaicin wurin shigar ƙusa a cikin medullary da kuma gyara nakasar kusurwa a cikin sagittal plane.
Fluoroscopy
Ya kamata a sanya injin hannu na C a gefen teburin daga gefen da abin ya shafa, kuma idan likitan tiyata yana tsaye a gefen gwiwa da abin ya shafa, na'urar aunawa ya kamata ta kasance a kan na'urar hannu ta C kuma ta kusa. Wannan yana bawa likitan tiyata da likitan rediyo damar lura da na'urar cikin sauƙi, sai dai idan za a saka ƙusa mai ɗaurewa ta nesa. Ko da yake ba dole ba ne, marubutan sun ba da shawarar a motsa hannun C zuwa gefe ɗaya kuma likitan tiyata ya koma gefe ɗaya lokacin da za a tuƙa sukurori mai ɗaurewa ta tsakiya. A madadin haka, ya kamata a sanya injin hannu na C a gefen da abin ya shafa yayin da likitan tiyata ke yin aikin a gefen da abin ya shafa (Hoto na 3). Wannan ita ce hanyar da marubutan suka fi amfani da ita domin tana guje wa buƙatar likitan tiyata ya canza daga gefen tsakiya zuwa gefen gefe lokacin da yake tuƙa ƙusa mai ɗaurewa ta nesa.
Hoto na 3: Likitan tiyata yana tsaye a gefen tibia da abin ya shafa don a iya tuƙa sukurorin da ke tsakanin tsakiya cikin sauƙi. Nunin yana gaban likitan tiyata, a kan C-arm.
Ana samun dukkan hotunan da ke nuna anteroposterior da medial-lateral fluoroscopic ba tare da motsa gaɓar da abin ya shafa ba. Wannan yana hana matsar da wurin da aka sake saita karyewar kafin a gyara karyewar gaba ɗaya. Bugu da ƙari, ana iya samun hotunan cikakken tsawon tibia ba tare da karkatar da C-arm ta hanyar da aka bayyana a sama ba.
Yankewar fata Duk yankewar da aka yi wa fatar jiki mai iyaka da kuma wanda aka tsawaita sosai sun dace. Hanyar yankewa ta hanyar amfani da ƙusa ta ciki ta hanyar amfani da yankewa mai tsawon santimita 3 don tuƙa ƙusa. Yawancin waɗannan yankewar tiyata suna da tsayi, amma kuma suna iya zama masu juyawa, kamar yadda Dr. Morandi ya ba da shawarar, kuma an nuna tsawaita yankewar da Dr. Tornetta da wasu suka yi amfani da ita ga marasa lafiya da ke da haɗin gwiwa na patellar subluxation, waɗanda galibi suna da hanyar parapatellar ta tsakiya ko ta gefe. Hoto na 4 yana nuna yankewar daban-daban.
Hoto na 4: Zane-zane na hanyoyin yankewa daban-daban na tiyata.1- Hanyar haɗin gwiwa ta suprapatellar; 2- Hanyar haɗin gwiwa ta parapatellar; 3- Hanyar haɗin gwiwa ta parapatellar mai iyaka; 4- Hanyar haɗin gwiwa ta parapatellar mai tsawo; 5- Hanyar haɗin gwiwa ta parapatellar ta gefe. Zurfin fallasar hanyar haɗin gwiwa ta parapatellar na iya kasancewa ta hanyar haɗin gwiwa ko kuma a wajen bursa na haɗin gwiwa.
Bayyanawa mai zurfi
Ana yin hanyar da aka yi amfani da ita wajen raba jijiyar quadriceps ta hanyar amfani da dogon lokaci har sai ramin ya iya ɗaukar nauyin kayan aiki kamar ƙusoshin intramedullary. Hakanan ana iya nuna hanyar da aka yi amfani da ita wajen haɗa jijiyar parapatellar, wadda ke ratsa kusa da tsokar quadriceps, don amfani da hanyar da aka yi amfani da ita wajen haɗa jijiyar tibial. Ana iya ratsa allurar trocar mai laushi da cannula ta hanyar haɗin patellofemoral, wata hanya da ke jagorantar wurin shiga na gaba da na sama na ƙusa ta tibial ta hanyar trocar na femoral. Da zarar an sanya trocar daidai, dole ne a ɗaure shi a wurin don guje wa lalacewa ga guringuntsi na gwiwa.
Ana iya amfani da babban hanyar yankewa ta hanyar transligamentous tare da hanyar yanke fata ta hyperextension parapatellar, ko dai ta hanyar tsakiya ko ta gefe. Duk da cewa wasu likitocin tiyata ba sa kiyaye bursa cikin sauƙi a lokacin tiyata, Kubiak da abokan aikinsa sun yi imanin cewa ya kamata a kiyaye bursa cikin sauƙi kuma ya kamata a fallasa shi yadda ya kamata gaɓoɓin da ke cikin ƙashi. A ka'ida, wannan yana ba da kyakkyawan kariya ga haɗin gwiwa na gwiwa kuma yana hana lalacewa kamar kamuwa da gwiwa.
Hanyar da aka bayyana a sama ta haɗa da cirewar patella daga jiki, wanda ke rage matsin lamba a saman haɗin gwiwa zuwa wani mataki. Idan yana da wahala a yi gwajin haɗin gwiwa na patellofemoral tare da ƙaramin ramin haɗin gwiwa da na'urar faɗaɗa gwiwa mai iyaka sosai, marubutan sun ba da shawarar cewa patella za a iya raba ta rabi ta hanyar rabuwar ligament. A gefe guda kuma, yankewar da aka yi ta tsakiya tana guje wa lalacewa ga jijiyoyin da ke tallafawa, amma yana da wuya a yi nasarar gyara raunin gwiwa.
Wurin shigar allurar SPN iri ɗaya ne da na hanyar infrapatellar. Binciken fluoroscopy na gaba da na gefe yayin saka allura yana tabbatar da cewa wurin shigar allura daidai ne. Likitan tiyata dole ne ya tabbatar da cewa allurar jagora ba a tura ta nesa da baya zuwa cikin tibia na gaba ba. Idan an tura ta da zurfi sosai a baya, ya kamata a sake sanya ta tare da taimakon ƙusa mai toshewa a ƙarƙashin hoton coronal na baya. Bugu da ƙari, Eastman da abokan aikinsa sun yi imanin cewa haƙa fil ɗin shiga a cikin wurin gwiwa mai lanƙwasa yana taimakawa wajen sake sanya karyewa a cikin wurin da aka faɗaɗa sosai.
Kayan aikin ragewa
Kayan aiki masu amfani don ragewa sun haɗa da ƙarfin rage maki mai girma dabam-dabam, na'urorin ɗaga ƙafa, na'urorin gyarawa na waje, da na'urorin gyarawa na ciki don gyara ƙananan gutsuttsuran karyewa da farantin cortical guda ɗaya. Hakanan ana iya amfani da ƙusoshin toshewa don tsarin ragewa da aka ambata a sama. Ana amfani da guduma don gyara kusurwar sagittal da nakasar juyawar juyawa.
Dashen dashen
Yawancin masana'antun gyaran ƙafafu na ciki sun ƙirƙiro tsarin amfani da kayan aiki don jagorantar wurin da aka sanya ƙusoshin tibial intramedullary. Ya haɗa da hannun da aka shimfiɗa a tsaye, na'urar auna tsawon fil mai jagora, da kuma mai faɗaɗa medullary. Yana da matuƙar muhimmanci cewa fil ɗin trocar da trocar masu ƙyalli suna kare hanyar shiga ƙusa ta intramedullary da kyau. Likitan tiyata dole ne ya sake tabbatar da matsayin cannula don kada rauni ga haɗin gwiwa na patellofemoral ko tsarin periarticular saboda kusanci da na'urar tuƙi sosai.
Sukurori Masu Kullewa
Likitan tiyata dole ne ya tabbatar da cewa an saka isasshen adadin sukurori masu kullewa don kiyaye raguwa mai kyau. Ana yin gyaran ƙananan gutsuttsuran karyewa (kusa ko nesa) da sukurori 3 ko fiye tsakanin gutsuttsuran karyewa da ke kusa, ko kuma da sukurori masu kusurwa ɗaya kawai. Hanyar da ta fi dacewa da dabarar ƙusa ta tibial intramedullary ta yi kama da hanyar infrapatellar dangane da dabarar tuƙi. Ana sarrafa sukurori masu kullewa daidai gwargwado ta hanyar amfani da fluoroscopy.
Rufe rauni
Tsoka da mayafin waje mai dacewa yayin faɗaɗawa yana cire ragowar ƙashi kyauta. Duk raunuka suna buƙatar a yi musu ban ruwa sosai, musamman wurin tiyatar gwiwa. Sannan a rufe jijiyar quadriceps ko layin ligament da dinkin da ke wurin da ya fashe, sannan a rufe fatar fata da fata.
Cire ƙusa ta intramedullary
Ko za a iya cire ƙusa ta tibial intramedullary da aka tura ta hanyar suprapatellar ta hanyar tiyata daban-daban har yanzu ana ci gaba da cece-kuce. Hanyar da aka fi amfani da ita ita ce hanyar transarticular suprapatellar don cire ƙusa ta intramedullary. Wannan dabarar tana fallasa ƙusa ta hanyar haƙa ta hanyar hanyar ƙusa ta suprapatellar intramedullary ta amfani da wani rami mai rami mai girman 5.5 mm. Sannan ana tura kayan aikin cire ƙusa ta hanyar hanyar, amma wannan aikin na iya zama da wahala. Hanyoyin parapatellar da infrapatellar hanyoyi ne na cire ƙusa ta intramedullary.
Hadarin da ke tattare da tiyatar da ake yi wa hanyar tiyata ta hanyar amfani da ƙusa ta tibial intramedullary su ne raunin lafiya ga guringuntsi na patella da femoral talus, raunin lafiya ga wasu sassan cikin haɗin gwiwa, kamuwa da cuta a haɗin gwiwa, da tarkace a cikin haɗin gwiwa. Duk da haka, akwai rashin rahotannin shari'o'in asibiti masu dacewa. Marasa lafiya da ke fama da chondromalacia za su fi fuskantar raunin guringuntsi da likita ya haifar. Lalacewar lafiya ga tsarin saman haɗin gwiwa na patellar da femoral babban abin damuwa ne ga likitocin tiyata da ke amfani da wannan hanyar tiyata, musamman hanyar transarticular.
Zuwa yanzu, babu wata shaidar asibiti ta ƙididdiga kan fa'idodi da rashin amfanin dabarar ƙusa ta tibial intramedullary ta semi-extension.
Lokacin Saƙo: Oktoba-23-2023
