Navicular malunion amapezeka pafupifupi 5-15% ya fractures onse pachimake wa navicular fupa, ndi navicular necrosis zikuchitika pafupifupi 3%. Zowopsa za malunion panyanja zimaphatikizapo kuphonya kapena kuchedwa kuzindikira, kuyandikira kwa mzere wosweka, kusamuka kwakukulu kuposa 1 mm, ndi kupasuka ndi kusakhazikika kwa carpal. Ngati sichitsatiridwa, navicular osteochondral nonunion nthawi zambiri imagwirizanitsidwa ndi nyamakazi yowopsya, yomwe imadziwikanso kuti navicular osteochondral nonunion ndi collapsing osteoarthritis.
Kulumikiza mafupa ndi kapena opanda vascularised flap angagwiritsidwe ntchito pochiza navicular osteochondral nonunion. Komabe, kwa odwala omwe ali ndi osteonecrosis ya proximal pole ya navicular fupa, zotsatira za kulumikiza mafupa popanda nsonga ya mitsempha ndizosasangalatsa, ndipo kuchiritsa kwa fupa kumangokhala 40% -67%. Mosiyana ndi izi, machiritso a mafupa ophatikizika ndi vascularised flaps akhoza kufika 88% -91%. Kuphulika kwakukulu kwa fupa la vascularised pazachipatala kumaphatikizapo 1,2-ICSRA-tipped distal radius flap, kumezanitsa mafupa + vascular bundle implant, palmar radius flap, free iliac bone flap with vascularised nsonga, ndi medial femoral condylar bone flap (MFC VBG), etc. Zotsatira za mafupa kulumikiza ndi vascularised nsonga ndi zogwira mtima. MFC VBG yaulere yasonyezedwa kuti ndi yothandiza pochiza ma fractures a navicular ndi kugwa kwa metacarpal, ndipo MFC VBG imagwiritsa ntchito nthambi ya articular ya mitsempha yotsika ya mawondo monga nthambi yaikulu ya trophic. Poyerekeza ndi ma flaps ena, MFC VBG imapereka chithandizo chokwanira chothandizira kubwezeretsa mawonekedwe a fupa la navicular, makamaka mu navicular fracture osteochondrosis ndi kupunduka kwa msana (Chithunzi 1). Pochiza navicular osteochondral osteonecrosis yokhala ndi kugwa kwapang'onopang'ono kwa carpal, 1,2-ICSRA-nsonga ya distal radius flap yanenedwa kuti ili ndi machiritso a mafupa a 40% okha, pomwe MFC VBG ili ndi machiritso a mafupa a 100%.
Chithunzi 1. Kuphwanyidwa kwa fupa la navicular ndi "kuwerama kumbuyo" kupunduka, CT imasonyeza chipika chophwanyika pakati pa mafupa a navicular pamtunda wa pafupifupi 90 °.
Kukonzekera koyambirira
Pambuyo pakuwunika kwa mkono womwe wakhudzidwa, kafukufuku wojambula ayenera kuchitidwa kuti awone kuchuluka kwa kugwa kwa dzanja. Ma radiographs osavuta ndi othandiza kutsimikizira komwe kuphulikako, kuchuluka kwa kusamuka, komanso kukhalapo kwa resorption kapena sclerosis yosweka. Zithunzi zam'mbuyo zam'mbuyo zimagwiritsidwa ntchito poyesa kugwa kwa dzanja, kusakhazikika kwa mkono (DISI) pogwiritsa ntchito chiŵerengero cha kutalika kwa dzanja (kutalika / m'lifupi) ≤1.52 kapena ngodya yozungulira yozungulira yoposa 15 °. MRI kapena CT ingathandize kuzindikira kusayenda bwino kwa navicular bone kapena osteonecrosis. Ma radiographs kapena oblique sagittal CT ya navicular bone ndi navicular angle> 45 ° imasonyeza kufupikitsa fupa la navicular, lomwe limadziwika kuti "bowed back deformity".MRI T1, T2 low signal imasonyeza necrosis ya navicular bone, koma MRI ili ndi palibe tanthauzo lodziwikiratu pakuzindikira machiritso a fracture.
Zizindikiro ndi contraindications:
Navicular osteochondral nonunion ndi wowerama kumbuyo chilema ndi DISI; MRI limasonyeza ischemic necrosis wa navicular fupa, intraoperative kumasulira kwa tourniquet ndi kuona wosweka wosweka mapeto a navicular fupa akadali woyera sclerotic fupa; Kulephera kwa kulumikiza kwa fupa loyambira kapena wononga mkati kumafuna kulumikiza kwa mafupa a VGB (＞1cm3). zotsatira za preoperative kapena intraoperative za osteoarthritis wa radial carpal joint; ngati malunion odziwika kwambiri omwe ali ndi nyamakazi yakugwa, ndiye kuti kufooka kwa dzanja, osteotomy ya navicular, kuphatikizika kwa quadrangular, proximal carpal osteotomy, kuphatikizika kwathunthu kwa carpal, ndi zina zotero, kungafunike; navicular malunion, proximal necrosis, koma ndi yachibadwa navicular fupa morphology (mwachitsanzo, sanali kusamutsidwa navicular fracture ndi osauka magazi kwa proximal pole); kufupikitsa malunion navicular popanda osteonecrosis. (1,2-ICSRA itha kugwiritsidwa ntchito ngati choloweza m'malo mwa distal radius flap).
Anatomy Yogwiritsidwa Ntchito
MFC VBG imaperekedwa ndi ziwiya zazing'ono za interosseous trophoblastic (zikutanthauza 30, 20-50), ndi magazi ochuluka kwambiri omwe amakhala otsika kwambiri kuposa amtundu wamkati wa femoral condyle (amatanthauza 6.4), otsatiridwa ndi apamwamba kwambiri (amatanthauza 4.9) ( Chithunzi 2). Mitsempha ya trophoblastic iyi idaperekedwa makamaka ndi mtsempha wotsika wa geniculate (DGA) ndi / kapena mtsempha wapamwamba kwambiri wapakati (SMGA), womwe ndi nthambi ya mtsempha wachikazi wowoneka bwino womwe umapangitsanso nthambi za articular, musculocutaneous, ndi/kapena saphenous mitsempha. . DGA idachokera ku mtsempha wachikazi wapakatikati mpaka kumtunda wapakati wa medial malleolus, kapena pamtunda wa 13.7 cm motalikirana ndi pamwamba (10.5-17.5 cm), ndipo kukhazikika kwa nthambi kunali 89% mu zitsanzo za cadaveric. (Chithunzi 3). DGA imachokera ku mitsempha yachikazi yachikazi yomwe ili pamtunda wa 13.7 cm (10.5 cm-17.5 cm) pafupi ndi pakati pa malleolus fissure kapena pafupi ndi articular pamwamba, ndi chitsanzo cha cadaveric chosonyeza 100% kukhazikika kwa nthambi ndi m'mimba mwake pafupifupi 0.78 mm. Choncho, kaya DGA kapena SMGA ndi yovomerezeka, ngakhale kuti yoyambayo ndi yoyenera kwambiri kwa tibiae chifukwa cha kutalika ndi m'mimba mwake.
Chithunzi cha 2. Kugawidwa kwa magawo anayi a zombo za MFC trophoblast motsatira mzere wopingasa pakati pa semitendinosus ndi mgwirizano wapakati wa A, mzere wa trochanter B, mzere wapamwamba wa patella C, mzere wa anterior meniscus D.
Chithunzi 3. MFC vascular anatomy: (A) Zowonjezera nthambi ndi MFC trophoblastic vascular anatomy, (B) Kutalikirana kwa mitsempha yochokera ku mzere wolumikizana
Kupeza opaleshoni
Wodwalayo amaikidwa pansi pa anesthesia wamba pa malo a supine, ndi mwendo wokhudzidwawo umayikidwa pa tebulo la opaleshoni ya manja. Kawirikawiri, fupa la fupa loperekera limatengedwa kuchokera ku ipsilateral medial femoral condyle, kuti wodwalayo azitha kuyenda ndi ndodo pambuyo pa opaleshoni. Bondo lotsutsana likhoza kusankhidwanso ngati pali mbiri ya kuvulala koyambirira kapena opaleshoni kumbali yomweyo ya bondo. Bondo limasinthasintha ndipo chiuno chimazungulira kunja, ndipo maulendo oyendayenda amagwiritsidwa ntchito kumtunda ndi kumunsi. Njira yopangira opaleshoniyo inali njira yowonjezera ya Russe, yomwe imayambira 8 masentimita pafupi ndi msewu wodutsa wa carpal ndikukwera kutali kuchokera m'mphepete mwa radial flexor carpi radialis tendon, ndiyeno kupindika pamtunda wa carpal kumunsi kwa chala chachikulu. , kutha pa mlingo wa trochanter wamkulu. Mphuno ya tendon ya radial longissimus tendon imadulidwa ndipo tendon imakokedwa mosalekeza, ndipo fupa la navicular limawululidwa ndi kugawanika kwakuthwa pamodzi ndi mitsempha yamtundu wa radial lunate ndi radial navicular head ligaments, ndi kulekanitsa mosamala minofu yofewa ya fupa la navicular kuti ilole. kuwonekera kwina kwa fupa la navicular (Chithunzi 4). Tsimikizirani dera la nonnunion, mtundu wa articular cartilage ndi kuchuluka kwa ischemia ya navicular bone. Pambuyo kumasula tourniquet, onani proximal mzati wa navicular fupa kwa punctate magazi kudziwa ngati pali ischemic necrosis. Ngati navicular necrosis sikugwirizana ndi radial carpal kapena intercarpal nyamakazi, MFC VGB ingagwiritsidwe ntchito.
Chithunzi 4. Njira yopangira opaleshoni ya navicular: (A) Kuwombera kumayambira 8 masentimita moyandikana ndi msewu wodutsa wa carpal ndikuwonjezera m'mphepete mwa radial flexor carpi radialis tendon ku mbali ya distal ya incision, yomwe imapindika kumunsi kwa chala chachikulu. panjira yodutsa carpal. (B) Mphuno ya tendon ya radial longissimus tendon imadulidwa ndipo tendon imakokedwa ulnarly, ndipo fupa la navicular limawululidwa ndi dissection lakuthwa pamodzi ndi radial lunate ndi radial navicular head ligaments. (C) Dziwani malo a navicular osseous discontinuity.
Kudulidwa kwautali wa 15-20 masentimita kumapangidwa moyandikana ndi mzere wolumikizana ndi bondo m'mphepete chakumbuyo kwa minofu yapakati ya chikazi, ndipo minofu imachotsedwa kutsogolo kuti iwonetsetse magazi a MFC (mkuyu 5) .Magazi a MFC nthawi zambiri amaperekedwa ndi nthambi za DGA ndi SMGA, nthawi zambiri zimatengera nthambi yayikulu ya DGA ndi mtsempha wotsatira. Mitsempha ya mitsempha imamasulidwa pafupi, kusamala kuteteza periosteum ndi ziwiya za trophoblastic pamtunda wa bony.
Chithunzi 5. Opaleshoni yopita ku MFC: (A) Kudula kwa 15-20 masentimita kumapangidwira pafupi ndi malire a m'mphepete mwa mitsempha yapakati ya chikazi kuchokera pamzere wa mawondo. (B) Minofu imachotsedwa kutsogolo kuti iwonetse magazi a MFC.
Kukonzekera kwa navicular fupa
Kupunduka kwa navicular DISI kuyenera kukonzedwa ndipo malo a osteochondral bone graft amakonzedwa asanakhazikitsidwe mwa kusinthasintha dzanja pansi pa fluoroscopy kuti abwezeretsenso ngodya yabwino ya radial lunate (Chithunzi 6). Pini ya 0.0625-foot (pafupifupi 1.5-mm) Kirschner pini imabowoleredwa kuchokera ku dorsal kupita ku metacarpal kuti ikonzenso mgwirizano wa kuwala kwa mwezi, ndipo kusiyana kwa malunion kumawonekera pamene dzanja lawongoka. Malo ophwanyika adachotsedwa minofu yofewa ndikutsegulidwanso ndi mbale yofalitsa. Macheka ang'onoang'ono obwerezabwereza amagwiritsidwa ntchito kuti aphwanyidwe fupa ndikuwonetsetsa kuti choyikapo choyikapo chikufanana ndi mawonekedwe amakona anayi kuposa mphero, zomwe zimafuna kuti kusiyana kwa navicular kuchitidwe ndi kusiyana kwakukulu kumbali ya palmar kusiyana ndi mbali ya dorsal. Pambuyo potsegula mpata, chilemacho chimayesedwa m'miyeso itatu kuti mudziwe kukula kwa mafupa a mafupa, omwe nthawi zambiri amakhala 10-12 mm kutalika kumbali zonse za kumezanitsa.
Chithunzi 6. Kuwongolera kwa kupindika kwa msana kwa navicular, ndi fluoroscopic flexion of wrist kuti abwezeretse kusintha kwabwino kwa mwezi. Pini ya 0.0625-foot (pafupifupi 1.5-mm) Kirschner pini imabowoleredwa mosadukiza kuchokera ku dorsal kupita ku metacarpal kuti ikhazikitse cholumikizira cha radial lunate, kuwonetsa kusiyana kwa malunion navicular ndikubwezeretsa kutalika kwabwino kwa fupa la navicular pamene dzanja lawongoka, ndi kukula kwake. mpata wolosera kukula kwa chotchinga chomwe chidzafunika kulumikizidwa.
Osteotomy
Malo a vascularised of the medial femoral condyle amasankhidwa ngati malo opangira mafupa, ndipo malo opangira mafupa amalembedwa mokwanira. Samalani kuti musawononge mitsempha yapakati. Periosteum imadulidwa, ndipo fupa la fupa la rectangular la kukula koyenera kwa chiwombankhanga chofunidwa chimadulidwa ndi macheka obwerezabwereza, ndi fupa lachiwiri lodulidwa pa 45 ° pambali imodzi kuti zitsimikizire kukhulupirika kwa chowombera (mkuyu 7). 7). Chisamaliro chiyenera kutengedwa kuti musalekanitse periosteum, cortical bone, ndi cancellous bone of the flap. Mtsinje wam'munsi uyenera kumasulidwa kuti muwone momwe magazi akuyendera pamphuno, ndipo mitsempha ya mitsempha iyenera kumasulidwa pafupi ndi masentimita 6 kuti alole anastomosis yotsatira ya mitsempha. Ngati ndi kotheka, fupa laling'ono la cancellous likhoza kupitilizidwa mkati mwa condyle yachikazi. Chilema cha femoral condylar chimadzazidwa ndi cholowa m'malo mwa fupa, ndipo chodulidwacho chimatsanulidwa ndikutsekedwa ndi wosanjikiza.
Chithunzi 7. MFC bone flap kuchotsa. (A) Malo otchedwa osteotomy okwanira kudzaza malo oyendamo amalembedwa, periosteum imadulidwa, ndipo fupa la fupa la rectangular la kukula koyenera kwa chiphuphu chomwe mukufuna chimadulidwa ndi macheka obwereza. (B) Chigawo chachiwiri cha fupa chimadulidwa kumbali imodzi pa 45 ° kuti zitsimikizire kukhulupirika kwa chowombera.
Flap implantation ndi fixation
Chophimba cha fupa chimakonzedwa kuti chikhale choyenera, kusamala kuti musamangirire mitsempha ya mitsempha kapena kuvula periosteum. Chotchingacho chimayikidwa pang'onopang'ono m'dera la fupa la navicular, kupewa kugunda, ndikukhazikika ndi zomangira zopanda pake. Chisamaliro chinachitidwa kuti kuwonetsetse kuti m'mphepete mwa fupa loikidwa m'mphepete mwa fupa la navicular fupa limakhala lophwanyika kapena kuti linali lokhumudwa pang'ono kuti lisalowe. Fluoroscopy inachitidwa kuti itsimikizire navicular bone morphology, mzere wa mphamvu ndi malo owononga. Anastomose mtsempha wamtsempha wamagazi mpaka kumapeto kwa mtsempha wozungulira mpaka mbali ndi nsonga ya venous mpaka kumapeto kwa mtsempha wamagazi (Chithunzi 8). The kapisozi olowa kukonzedwa, koma mtima pedicle amapewa.
Chithunzi 8. Kuyika kwa mafupa a mafupa, kukonza, ndi vascular anastomosis. Mphepete mwa fupa imayikidwa pang'onopang'ono m'dera la fupa la navicular ndikukhazikika ndi zomangira zopanda pake kapena zikhomo za Kirschner. Chisamaliro chimatengedwa kuti m'mphepete mwa metacarpal wa fupa lobzalidwa lopangidwa ndi metacarpal m'mphepete mwa fupa la navicular kapena kupsinjika pang'ono kuti musalowe. Anastomosis ya mitsempha ya mitsempha yopita ku mitsempha yozungulira inachitidwa kumapeto mpaka kumapeto, ndipo nsonga ya mitsempha yopita ku mtsempha wamtundu wa radial inachitidwa kumapeto mpaka kumapeto.
Kukonzanso pambuyo pa opaleshoni
Aspirin oral 325 mg patsiku (kwa mwezi wa 1), kulemera kwa pambuyo pa opaleshoni kumaloledwa, kugwedeza mawondo kungachepetse kukhumudwa kwa wodwalayo, malingana ndi momwe wodwalayo amatha kusuntha panthawi yoyenera. Thandizo lotsutsana la ndodo imodzi lingathe kuchepetsa ululu, koma kuthandizira kwa nthawi yaitali kwa ndodo sikofunikira. Zomangirazo zidachotsedwa patatha milungu iwiri atachitidwa opaleshoni ndipo Muenster kapena mkono wautali mpaka chala chachikulu adasungidwa kwa milungu itatu. Pambuyo pake, mkono waufupi kupita ku chala chachikulu umagwiritsidwa ntchito mpaka kusweka kuchira. X-ray imatengedwa pakadutsa masabata a 3-6, ndipo machiritso a fracture amatsimikiziridwa ndi CT. Pambuyo pake, kusinthasintha kwachangu komanso kosasunthika ndi ntchito zowonjezera ziyenera kuyambika pang'onopang'ono, ndipo mphamvu ndi nthawi zambiri zolimbitsa thupi ziyenera kuwonjezeka pang'onopang'ono.
Zovuta zazikulu
Zovuta zazikulu za mgwirizano wa mawondo zimaphatikizapo kupweteka kwa mawondo kapena kuvulala kwa mitsempha. Kupweteka kwa bondo makamaka kunachitika mkati mwa masabata a 6 pambuyo pa opaleshoni, ndipo palibe kutayika kwakumva kapena kupweteka kwa neuroma chifukwa cha kuvulala kwa mitsempha ya saphenous. Zovuta zazikulu zapamanja zimaphatikizira kusagwirizana kwa mafupa, kupweteka, kulimba kwa mafupa, kufooka, osteoarthritis wopitilira muyeso wa dzanja la radial kapena mafupa a intercarpal, komanso chiopsezo cha periosteal heterotopic ossification zanenedwanso.
Free Medial Femoral Condyle Vascularised Bone Grafting for Scaphoid Nonunions with Proximal Pole Avascular Necrosis ndi Carpal Collapse
Nthawi yotumiza: May-28-2024
