Hanyar suprapatellar wata hanyar tiyata ce da aka gyara don ƙusa intramedullary na tibial a cikin matsakaicin matsayi na gwiwa.Akwai fa'idodi da yawa, amma kuma rashin amfani, don yin ƙusa intramedullary na tibia ta hanyar tsarin suprapatellar a cikin matsayi na hallux valgus.Wasu likitocin fiɗa sun saba da amfani da SPN don magance duk karayar tibial sai dai karaya da ke kusa da 1/3 na tibia.
Alamomi ga SPN sune:
1. Ƙarfafawa ko ɓarna na tushen tibial.2;
2. karaya na distal tibial metaphysis;
3. Karyewar hanji ko gwiwa tare da iyakancewar da aka rigaya na jujjuyawa (misali, haɗin gwiwa na hip ko fusion, osteoarthritis na gwiwa) ko rashin iya jujjuya gwiwa ko hip (misali, raguwa na baya na hip, karaya na ipsilateral). femur);
4. karayar tibial hade tare da rauni na fata a tendon infrapatellar;
5. karayar tibial a cikin majiyyaci tare da tibia mai tsayi da yawa (ƙarshen kusa da tibia sau da yawa yana da wuya a iya gani a karkashin fluoroscopy lokacin da tsayin tibia ya wuce tsawon lokacin tafiya wanda fluoroscopy zai iya wucewa).
Amfanin ƙwanƙwasa madaidaiciyar ƙusa tibial intramedullary dabarar ƙusa don maganin tsakiyar tibial diaphysis da ɓarkewar tibial mai nisa ya ta'allaka ne cikin sauƙi na sakewa da sauƙi na fluoroscopy.Wannan tsarin yana ba da damar kyakkyawan goyon baya na cikakken tsayin tibia da sauƙi na raguwa na sagittal na raguwa ba tare da buƙatar magudi ba (Figures 1, 2).Wannan yana kawar da buƙatar mataimaki mai horarwa don taimakawa da fasahar ƙusa ta intramedullary.
Hoto 1: Matsayi na al'ada don fasaha na ƙusa na intramedullary don tsarin infrapatellar: gwiwa yana cikin matsayi mai sauƙi a kan wani nau'i mai nau'i na fluoroscopically.Duk da haka, wannan matsayi na iya kara tsananta rashin daidaituwa na ƙaƙƙarfan toshe kuma yana buƙatar ƙarin fasahohin raguwa don raguwa.
Hoto 2: Sabanin haka, matsakaicin matsayi na gwiwa a kan kumfa mai kumfa yana sauƙaƙe daidaitawar toshewar fashewa da magudi na gaba.
Dabarun tiyata
Tebura/ Matsayi Mara lafiyan yana kwance a cikin madaidaicin matsayi akan gadon fluoroscopic.Za'a iya yin ƙusar ƙanƙara na ƙananan ƙafa, amma ba lallai ba ne. Tebur na Vascular ya dace sosai don tsarin suprapatellar tibial intramedullary ƙusa, amma ba lallai ba ne.Duk da haka, yawancin gadaje kafa gadaje ko gadaje masu haske ba a ba da shawarar ba saboda ba su dace da kusancin ƙusa na intramedullary na suprapatellar ba.
Ƙunƙarar cinyar ipsilateral yana taimakawa wajen kiyaye ƙananan ƙananan a cikin wani wuri mai juyawa na waje.Sannan ana amfani da kumfa mara kyau don ɗaga gaɓoɓin da abin ya shafa sama da gefen gefe don yin fluoroscopy na baya, kuma gurɓataccen matsayi na hip da gwiwa shima yana taimakawa wajen jagorantar ƙusa na intramedullary.Har yanzu ana muhawara mafi kyawun kusurwar jujjuya gwiwa, tare da Beltran et al.yana ba da shawarar ƙwanƙwasa 10 ° da Kubiak yana ba da shawarar ƙwanƙwasa 30 °.Yawancin malamai sun yarda cewa kusurwar gwiwar gwiwa a cikin waɗannan jeri suna karɓa.
Koyaya, Eastman et al.ya gano cewa yayin da aka ƙara girman kusurwar gwiwa a hankali daga 10 ° zuwa 50 °, an rage tasirin takin femoral akan shigar da kayan aiki na wucin gadi.Sabili da haka, babban kusurwar ƙwanƙwasa gwiwa zai taimaka wajen zaɓar madaidaicin shigarwar ƙusa intramedullary da kuma gyara nakasar kusurwa a cikin jirgin sama na sagittal.
Fluoroscopy
Ya kamata a sanya na'urar C-arm a gefen teburin daga gefen da abin ya shafa, kuma idan likitan tiyata yana tsaye a gefen gwiwa, mai duba ya kamata ya kasance a kan na'urar C-arm kuma kusa da shi. .Wannan yana ba likitan tiyata da likitan rediyo damar lura da na'urar cikin sauƙi, sai dai lokacin da za a saka ƙusa mai tsaka-tsaki.Ko da yake ba wajibi ba ne, marubutan sun ba da shawarar cewa a motsa C-arm zuwa gefe ɗaya kuma likitan fiɗa zuwa wani gefen lokacin da za a yi amfani da tsaka-tsakin tsaka-tsakin tsaka-tsakin.A madadin haka, ya kamata a sanya na'urar C-arm a gefen da abin ya shafa yayin da likitan fiɗa ya yi aikin a gefen da aka saba (Figure 3).Wannan ita ce hanyar da marubuta suka fi amfani da ita domin yana guje wa buƙatar likitan fiɗa daga gefen tsaka-tsaki zuwa gefen gefe yayin tuki ƙusa mai nisa.
Hoto na 3: Likitan fiɗa yana tsaye a gefen kishiyar tibia da ta shafa ta yadda za'a iya fitar da tsaka-tsakin tsaka-tsaki cikin sauƙi.Nunin yana gaban likitan tiyata, a kan C-arm.
Ana samun duk ra'ayoyin anteroposterior da tsaka-tsaki na fluoroscopic ba tare da motsa sashin da ya shafa ba.Wannan yana guje wa ƙaura daga wurin karyewar da aka sake saitawa kafin a gyara karayar gaba ɗaya.Bugu da ƙari, ana iya samun hotuna na tsawon tsayin tibia ba tare da karkatar da C-arm ta hanyar da aka bayyana a sama ba.
Ciwon fata Dukan ƙayyadaddun ƙayyadaddun ƙayyadaddun ƙayyadaddun ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfan ƙaƙƙarfar fata duka sun dace.Hanyar suprapatellar ta hanyar ƙusa ta intramedullary ta dogara ne akan yin amfani da ƙusa mai tsayi 3 cm don fitar da ƙusa.Yawancin waɗannan ɓangarorin tiyata suna da tsayi, amma kuma suna iya jujjuya su, kamar yadda Dokta Morandi ya ba da shawarar, kuma tsayin daka da Dr. Tornetta da sauransu ke amfani da shi ana nuna su a cikin marasa lafiya tare da haɗin gwiwa na patellar, waɗanda ke da matsakaicin matsakaici ko na gefe parapatellar. kusanci.Hoto na 4 yana nuna maɓalli daban-daban.
Hoto 4: Misali na hanyoyi daban-daban na tiyata.1- Suprapatellar transpatellar ligament tsarin;2- Hanyar ligament na Parapatellar;3- Medial iyaka incision parapatellar ligament kusanci;4- Tsawon tsaka-tsakin incision parapatellar ligament kusanci;5- Hankalin ligament na gefe.Hanya mai zurfi na tsarin ligament na parapatellar na iya zama ko dai ta hanyar haɗin gwiwa ko waje da haɗin gwiwa bursa.
Bayyanawa mai zurfi
Hanyar suprapatellar da ke da alaƙa ana yin ta da farko ta hanyar keɓance tendon quadriceps har sai tazarar zata iya ɗaukar hanyar kayan aiki kamar ƙusoshi na intramedullary.Hanyar ligament na parapatellar, wanda ke wucewa kusa da tsokar quadriceps, kuma ana iya nuna shi don fasahar ƙusa intramedullary na tibial.A hankali allura trocar trocar da cannula suna wucewa ta hanyar haɗin gwiwa na patellofemoral, hanyar da ke jagorantar gaba-gabatar shigarwar ƙusa intramedullary tibial ta hanyar trocar femoral.Da zarar trocar ya kasance daidai, dole ne a kiyaye shi a wurin don guje wa lalacewa ga guringuntsi na gwiwa.
Za'a iya amfani da babban tsarin incision na transligamentous tare da haɗin gwiwa tare da hyperextension parapatellar fata, tare da ko dai ta tsakiya ko ta gefe.Ko da yake wasu likitocin ba sa kiyaye bursa ta cikin aiki, Kubiak et al.yi imani da cewa ya kamata a kiyaye bursa da kyau kuma ya kamata a fallasa kayan da suka dace sosai.A ka'ida, wannan yana ba da kyakkyawan kariya ga haɗin gwiwa gwiwa kuma yana hana lalacewa kamar ciwon gwiwa.
Hanyar da aka bayyana a sama kuma ta haɗa da hemi-dislocation na patella, wanda ya rage karfin lamba a kan sassan articular zuwa wani matsayi.Lokacin da yake da wuya a yi kima na haɗin gwiwa na patellofemoral tare da ƙananan ƙananan haɗin gwiwa da kuma ƙayyadaddun ƙayyadaddun na'ura mai tsawo na gwiwa, marubutan sun ba da shawarar cewa za a iya raba patella ta hanyar rabuwar ligament.Matsakaicin tsaka-tsakin tsaka-tsakin, a gefe guda, yana guje wa lalacewa ga ligaments masu goyan baya, amma yana da wuya a yi nasarar gyara raunin gwiwa.
Wurin shigar da allura na SPN iri ɗaya ne da na tsarin infrapatellar.Fluoroscopy na gaba da na gefe yayin saka allura yana tabbatar da cewa wurin shigar allurar daidai ne.Dole ne likitan fiɗa ya tabbatar da cewa ba a kori allurar jagora da nisa daga baya zuwa cikin tibia na kusa.Idan an tuƙa shi da zurfi sosai a baya, yakamata a sake mayar da shi tare da taimakon ƙusa mai toshewa a ƙarƙashin ƙwayar cutar sankara na baya.Bugu da ƙari, Eastman et al.yi imani cewa hako fil ɗin shigarwa a cikin matsayi mai sassauƙa na gwiwa yana taimakawa a sake sanyawa karaya a matsayi mai tsayi.
Rage kayan aikin
Kayan aikin da ake amfani da su don ragewa sun haɗa da ƙarfin rage raguwa na nau'i daban-daban, masu hawan mata, na'urorin gyaran waje na waje, da masu gyara na ciki don gyaran ƙananan ɓawon burodi tare da faranti guda ɗaya.Hakanan za'a iya amfani da kusoshi masu toshewa don tsarin rage da aka ambata a sama.Ana amfani da hamarar ragewa don gyara sagittal angulation da nakasar ƙaura.
Shuka
Yawancin masana'antun na gyaran gyare-gyare na ciki na orthopedic sun haɓaka tsarin amfani da kayan aiki don jagorantar daidaitattun jeri na tibial intramedullary kusoshi.Ya haɗa da hanna mai tsayi, na'urar auna tsawon fil jagora, da faɗaɗa medullary.Yana da matukar mahimmanci cewa trocar da fitilun trocar mara kyau suna kare samun damar ƙusa na intramedullary da kyau.Dole ne likitan fiɗa ya sake tabbatar da matsayin cannula don kada rauni ga haɗin gwiwa na patellofemoral ko tsarin periarticular saboda kusanci da na'urar tuki ba ya faruwa.
Kulle Screws
Dole ne likitan fiɗa ya tabbatar da cewa an shigar da isassun adadin makullin kulle don kiyaye ragi mai gamsarwa.Ana yin gyaran gyare-gyaren ƙananan gutsuttsura (kusanci ko nisa) tare da 3 ko fiye na kulle sukurori tsakanin ɓangarorin da ke kusa da su, ko tare da kafaffen-kusurwoyi kadai.Hanyar suprapatellar zuwa dabarar ƙusa intramedullary tibial yayi kama da tsarin infrapatellar dangane da dabarun tuƙi.An fi fitar da sukurori daidai a ƙarƙashin fluoroscopy.
Rufe rauni
Tsotsawa tare da murfi mai dacewa a lokacin dilatation yana kawar da gutsuttsuran kashi kyauta.Duk raunuka suna buƙatar ban ruwa sosai, musamman wurin tiyatar gwiwa.Sai a rufe jijiyar quadriceps ko layin ligament da suture a wurin da ya fashe, sannan rufewar fata da fata.
Cire ƙusa intramedullary
Ko ƙusa intramedullary na tibial wanda aka kora ta hanyar suprapatellar za a iya cire shi ta wata hanyar tiyata ta daban ya kasance mai kawo rigima.Hanyar da aka fi sani da ita ita ce hanyar transarticular suprapatellar don kawar da ƙusa ta intramedullary.Wannan dabara tana fallasa ƙusa ta hanyar hakowa ta hanyar tashar ƙusa ta intramedullary na suprapatellar ta amfani da rawar rami na 5.5 mm.Ana amfani da kayan aikin cire ƙusa ta hanyar tashar, amma wannan motsi na iya zama da wahala.Hanyoyin parapatellar da infrapatellar sune madadin hanyoyin cire kusoshi na intramedullary.
Hatsari Hatsarin tiyata na tsarin suprapatellar zuwa dabarar ƙusa ta intramedullary na tibial sune rauni na likita ga patella da guringuntsi na talus na mata, rauni na likitanci ga wasu sifofin intra-articular, kamuwa da cuta na haɗin gwiwa, da tarkace na cikin-articular.Duk da haka, akwai rashin daidaitattun rahotanni na asibiti.Marasa lafiya tare da chondromalacia za su fi dacewa da raunin raunin guringuntsi na likita.Lalacewar likitanci ga sifofin bangon bangon bango da na mata babban abin damuwa ne ga likitocin masu yin amfani da wannan hanyar tiyata, musamman ma hanyar transarticular.
Har zuwa yau, babu wata shaida ta asibiti akan fa'ida da rashin amfani da dabarar ƙusa ta intramedullary na tibial Semi-extension.
Lokacin aikawa: Oktoba-23-2023
