Kusweka kwa mafupa a Navicular kumachitika pafupifupi 5-15% ya kusweka kwa mafupa a navicular, ndipo kusweka kwa mafupa a navicular kumachitika pafupifupi 3%. Zinthu zomwe zimayambitsa kusweka kwa mafupa a navicular ndi monga kuchedwa kapena kuchedwa kuzindikira, kuyandikira kwa mzere wosweka, kusamuka kwa mafupa opitirira 1 mm, ndi kusweka kwa mafupa ndi kusakhazikika kwa carpal. Ngati sichinachiritsidwe, kusweka kwa mafupa a navicular osteochondral nthawi zambiri kumagwirizanitsidwa ndi nyamakazi yoopsa, yomwe imadziwikanso kuti navicular osteochondral nonunion yokhala ndi osteoarthritis yogwa.
Kulumikiza mafupa pogwiritsa ntchito kapena popanda cholumikizira cha mitsempha kungagwiritsidwe ntchito pochiza matenda a navicular osteochondral nonunion. Komabe, kwa odwala omwe ali ndi osteonecrosis ya proximal pole ya navicular bone, zotsatira za kulumikiza mafupa popanda nsonga ya mitsempha sizikukhutiritsa, ndipo kuchuluka kwa kuchira kwa mafupa ndi 40%-67% yokha. Mosiyana ndi zimenezi, kuchuluka kwa kuchiritsa kwa zolumikizira mafupa pogwiritsa ntchito zolumikizira za mitsempha kungakhale kokwera kufika pa 88%-91%. Zolumikizira zazikulu za mafupa zomwe zimagwiritsidwa ntchito kuchipatala zimaphatikizapo 1,2-ICSRA-tipped distal radius flap, bone graft + vascular bundle implant, palmar radius flap, free iliac bone flap yokhala ndi nsonga ya mitsempha, ndi medial femoral condylar bone flap (MFC VBG), ndi zina zotero. Zotsatira za kulumikiza mafupa pogwiritsa ntchito nsonga ya mitsempha ndizokhutiritsa. Free MFC VBG yawonetsedwa kuti imagwira ntchito pochiza kusweka kwa navicular ndi metacarpal collapment, ndipo MFC VBG imagwiritsa ntchito nthambi ya articular ya descending bondo artery ngati nthambi yayikulu ya trophic. Poyerekeza ndi ma flaps ena, MFC VBG imapereka chithandizo chokwanira cha kapangidwe kake kuti ibwezeretse mawonekedwe abwinobwino a fupa la navicular, makamaka mu osteochondrosis ya navicular fracture yokhala ndi bow back deformity (Chithunzi 1). Pochiza osteonecrosis ya navicular osteochondral yokhala ndi progressive carpal collapse, 1,2-ICSRA-tipped distal radius flap yanenedwa kuti ili ndi 40% yokha yochira mafupa, pomwe MFC VBG ili ndi 100% yochira mafupa.
Chithunzi 1. Kusweka kwa fupa la navicular lomwe lili ndi vuto la "kubwerera mmbuyo", CT ikuwonetsa chotchinga cha kusweka pakati pa mafupa a navicular pa ngodya ya pafupifupi 90°.
Kukonzekera musanachite opaleshoni
Pambuyo pofufuza thupi la dzanja lomwe lakhudzidwa, maphunziro owunikira ayenera kuchitidwa kuti awone kuchuluka kwa kugwa kwa dzanja. Ma X-ray osavuta ndi othandiza kutsimikizira komwe kwasweka, kuchuluka kwa kusamuka, komanso kukhalapo kwa resorption kapena sclerosis ya mbali yosweka. Zithunzi za kumbuyo kwa kumbuyo zimagwiritsidwa ntchito poyesa kugwa kwa dzanja, kusakhazikika kwa dzanja (DISI) pogwiritsa ntchito chiŵerengero chosinthika cha kutalika kwa dzanja (kutalika/m'lifupi) cha ≤1.52 kapena ngodya ya radial lunate yoposa 15°. MRI kapena CT ingathandize kuzindikira kusalingana kwa fupa la navicular kapena osteonecrosis. Ma X-ray owonera mbali kapena CT ya oblique sagittal ya fupa la navicular yokhala ndi ngodya ya navicular >45° imasonyeza kufupikitsa kwa fupa la navicular, lomwe limadziwika kuti "bowed back deformity". MRI T1, T2 low signal imasonyeza necrosis ya fupa la navicular, koma MRI ilibe tanthauzo lodziwikiratu podziwa kuchira kwa kusweka.
Zizindikiro ndi zotsutsana:
Kusagwirizana kwa mafupa a m'chiuno ndi msana wopindika komanso DISI; MRI ikuwonetsa ischemic necrosis ya fupa la m'chiuno, kumasula kwa tourniquet mkati mwa opaleshoni ndikuwona kusweka komwe kwasweka kumapeto kwa fupa la m'chiuno ndi fupa loyera la sclerotic; kulephera kwa grafting yoyamba ya fupa kapena screw internal fixation kumafuna grafting yayikulu ya mafupa a VGB (> 1cm3). Zotsatira za osteoarthritis ya radial carpal joint isanachitike opaleshoni kapena mkati mwa opaleshoni; ngati pali vuto lalikulu la osteoarthritis ya m'chiuno ndi osteoarthritis yogwa, ndiye kuti kuchotsedwa kwa dzanja, osteotomy ya m'chiuno, quadrangular fusion, proximal carpal osteotomy, total carpal fusion, ndi zina zotero, zingafunike; navicular malunion, proximal necrosis, koma ndi mawonekedwe abwinobwino a mafupa a m'chiuno (monga, kusweka kwa mafupa a m'chiuno komwe sikunatuluke ndi magazi okwanira kupita ku proximal pole); kufupika kwa navicular malunion popanda osteonecrosis. (1,2-ICSRA ingagwiritsidwe ntchito m'malo mwa distal radius flap).
Kapangidwe ka Thupi
MFC VBG imaperekedwa ndi mitsempha ingapo yaing'ono ya trophoblastic yolumikizana (avereji 30, 20-50), pomwe magazi ambiri amakhala otsika kumbuyo kwa condyle ya femoral (avereji 6.4), kutsatiridwa ndi anteriorly superior (avereji 4.9) (Chithunzi 2). Mitsempha ya trophoblastic iyi imaperekedwa makamaka ndi descending geniculate artery (DGA) ndi/kapena superior medial geniculate artery (SMGA), yomwe ndi nthambi ya superior femoral artery yomwe imapanganso nthambi za mitsempha ya articular, musculocutaneous, ndi/kapena saphenous. DGA idachokera ku superior femoral artery yoyandikana ndi medial eminence ya medial malleolus, kapena patali wa 13.7 cm proximal kupita pamwamba pa articular (10.5-17.5 cm), ndipo kukhazikika kwa nthambi kunali 89% mu zitsanzo za mtembo (Chithunzi 3). DGA imachokera ku mtsempha wamagazi wa pamwamba pa femoral womwe uli pamtunda wa 13.7 cm (10.5 cm-17.5 cm) pafupi ndi mng'alu wa malleolus kapena pafupi ndi pamwamba pa articular, ndi chitsanzo cha mtembo chomwe chikuwonetsa kukhazikika kwa nthambi 100% ndi mainchesi pafupifupi 0.78 mm. Chifukwa chake, DGA kapena SMGA ndizovomerezeka, ngakhale yoyambayo ndi yoyenera kwambiri tibiae chifukwa cha kutalika ndi mainchesi a chotengeracho.
Chithunzi 2. Kugawa kwa ziwiya za trophoblast za MFC m'magawo anayi pamzere wopingasa pakati pa semitendinosus ndi medial collateral ligament A, mzere wa greater trochanter B, mzere wa superior pole ya patella C, mzere wa anterior meniscus D.
Chithunzi 3. Kapangidwe ka mitsempha ya MFC: (A) Nthambi zochulukirapo ndi kapangidwe ka mitsempha ya MFC trophoblastic, (B) Mtunda wa chiyambi cha mitsempha yamagazi kuchokera ku mzere wolumikizirana
Kupeza mwayi wochita opaleshoni
Wodwalayo amaikidwa pansi pa anesthesia wamba ali chafufumimba, ndipo mwendo wokhudzidwawo uli patebulo la opaleshoni ya dzanja. Kawirikawiri, chogwirira cha fupa choperekedwacho chimatengedwa kuchokera ku ipsilateral medial femoral condyle, kuti wodwalayo athe kuyenda ndi ndodo pambuyo pa opaleshoni. Bondo la contralateral lingasankhidwenso ngati pali mbiri ya kuvulala kapena opaleshoni yomwe idachitikapo mbali imodzi ya bondo. Bondo limapindika ndipo chiuno chimazunguliridwa kunja, ndipo ma tourniquet amayikidwa ku miyendo yonse yapamwamba ndi yapansi. Njira yochitira opaleshoni inali njira yowonjezera ya Russe, pomwe kudulako kumayambira 8 cm pafupi ndi ngalande yodutsa ya carpal ndikufalikira kutali ndi m'mphepete mwa radial ya radial flexor carpi radialis tendon, kenako kumapinda pa ngalande yodutsa ya carpal kupita pansi pa chala chachikulu, kutha pamlingo wa trochanter yayikulu. Chigoba cha tendon cha radial longissimus tendon chimadulidwa ndipo tendon imakokedwa mbali zonse, ndipo fupa la navicular limaonekera mwa kudulidwa kwambiri m'mitsempha ya radial lunate ndi radial navicular head ligaments, ndikulekanitsa mosamala minofu yofewa ya fupa la navicular kuti fupa la navicular liwonekere kwambiri (Chithunzi 4). Tsimikizirani malo osalumikizana, mtundu wa cartilage ya articular ndi kuchuluka kwa ischemia ya fupa la navicular. Mukamasula tourniquet, yang'anani nsonga ya proximal ya fupa la navicular kuti muwone ngati pali ischemic necrosis. Ngati navicular necrosis sikugwirizana ndi radial carpal kapena intercarpal arthritis, MFC VGB ingagwiritsidwe ntchito.
Chithunzi 4. Njira yopangira opaleshoni ya navicular: (A) Kuduladulaku kumayambira 8 cm pafupi ndi ngalande yopingasa ya carpal ndikukulitsa m'mphepete mwa radial ya radial flexor carpi radialis tendon mpaka mbali yakutali ya kudulaku, yomwe imapindidwa kupita pansi pa chala chachikulu pa ngalande yopingasa ya carpal. (B) Chigoba cha tendon cha radial longissimus tendon chimadulidwa ndipo tendon imakokedwa mbali zonse, ndipo fupa la navicular limaonekera poduladula kwambiri m'mitsempha ya radial lunate ndi radial navicular head ligaments. (C) Dziwani malo omwe pali kugawanika kwa mafupa a navicular.
Kucheka kwa kutalika kwa 15-20 cm kumapangidwa pafupi ndi mzere wolumikizira bondo m'mphepete mwa kumbuyo kwa minofu ya femoral yapakati, ndipo minofu imabwerera kumbuyo kuti iwonetse magazi a MFC (Chithunzi 5). Magazi a MFC nthawi zambiri amaperekedwa ndi nthambi za articular za DGA ndi SMGA, nthawi zambiri amatenga nthambi yayikulu yolumikizira ya DGA ndi mtsempha wofanana nawo. Mtsempha wa m'mimba umatulutsidwa pafupi, kuteteza periosteum ndi mitsempha ya trophoblastic pamwamba pa mafupa.
Chithunzi 5. Kulowera ku MFC opaleshoni: (A) Kucheka kwa 15-20 cm kutalika kumapangidwa pafupi ndi malire akumbuyo a minofu ya femoral yapakati kuchokera ku mzere wolumikizira bondo. (B) Minofu imabwereranso kutsogolo kuti magazi a MFC awonekere.。
Kukonzekera kwa fupa la navicular
Kufooka kwa navicular DISI kuyenera kukonzedwa ndipo malo a osteochondral bone graft amakonzedwa asanaikidwe mwa kupindikiza dzanja pansi pa fluoroscopy kuti abwezeretse ngodya ya radial lunate (Chithunzi 6). Pini ya Kirschner ya 0.0625-foot (pafupifupi 1.5-mm) imabowoledwa mozungulira kuchokera ku dorsal kupita ku metacarpal kuti ikonze cholumikizira cha radial lunate, ndipo navicular malunion gap imaonekera pamene dzanja liwongoledwa. Malo oswekawo amachotsedwa minofu yofewa ndipo amatsegulidwanso ndi chofalitsa mbale. Sowo yaying'ono yobwerezabwereza imagwiritsidwa ntchito kuti iphwasule fupa ndikuwonetsetsa kuti cholumikiziracho chikufanana ndi kapangidwe ka rectangle kuposa wedge, zomwe zimafuna kuti navicular gap igwiridwe ndi gap yayikulu kumbali ya kanjedza kuposa mbali ya dorsal. Pambuyo potsegula gap, cholakwikacho chimayesedwa m'magawo atatu kuti adziwe kukula kwa fupa graft, yomwe nthawi zambiri imakhala 10-12 mm kutalika mbali zonse za graft.
Chithunzi 6. Kukonza chilema cha msana chowerama cha navicular, ndi kupindika kwa dzanja pogwiritsa ntchito fluoroscopic kuti abwezeretse kulinganiza bwino kwa radial-lunar. Pini ya Kirschner ya 0.0625-foot (pafupifupi 1.5-mm) imabowoledwa mozungulira kuchokera ku dorsal kupita ku metacarpal kuti ikhazikitse cholumikizira cha radial lunate, kuwonetsa mpata wa navicular malunion ndikubwezeretsa kutalika kwabwinobwino kwa fupa la navicular pamene dzanja litawongoledwa, ndi kukula kwa mpata kuneneratu kukula kwa chivundikiro chomwe chidzafunika kugwidwa.
Osteotomy
Malo ozungulira mitsempha ya m'mimba ya femoral condyle amasankhidwa ngati malo ochotsera mafupa, ndipo malo ochotsera mafupa amalembedwa mokwanira. Samalani kuti musavulaze mitsempha ya m'mimba ya collateral ligament. Periosteum imadulidwa, ndipo fupa la rectangle flap la kukula koyenera kwa flap yomwe mukufuna limadulidwa ndi sosi yobwerezabwereza, ndi fupa lachiwiri lodulidwa pa 45° mbali imodzi kuti muwonetsetse kuti flap ndi yolimba (Chithunzi 7). 7). Samalani kuti musalekanitse periosteum, fupa la cortical, ndi fupa la cancellous la flap. Tourniquet ya m'munsi iyenera kutulutsidwa kuti ione momwe magazi akuyendera kudzera mu flap, ndipo vascular pedicle iyenera kumasulidwa pafupi ndi 6 cm kuti mitsempha yotsatira ituluke. Ngati pakufunika, fupa laling'ono la cancellous likhoza kupitilizidwa mkati mwa femoral condyle. Chilema cha femoral condylar chimadzazidwa ndi cholowa m'malo mwa fupa, ndipo kudulako kumachotsedwa madzi ndikutsekedwa ndi wosanjikiza.
Chithunzi 7. Kuchotsa chivundikiro cha mafupa cha MFC. (A) Malo ochotsera mafupa okwanira kudzaza malo a navicular amalembedwa chizindikiro, periosteum imadulidwa, ndipo chivundikiro cha mafupa cha rectangular cha kukula koyenera kwa chivundikiro chomwe mukufuna chimadulidwa ndi sosi yobwerezabwereza. (B) Chidutswa china cha fupa chimadulidwa mbali imodzi pa 45° kuti zitsimikizire kuti chivundikirocho chili bwino.
Kuyika ndi kuyika chivundikiro cha flap
Chifuwa cha fupa chimadulidwa kuti chikhale ndi mawonekedwe oyenera, kusamala kuti chisapanikize pedicle ya mitsempha yamagazi kapena kuchotsa periosteum. Chifuwacho chimayikidwa pang'onopang'ono pamalo omwe pali vuto la fupa la navicular, kupewa kugwedezeka, ndikukhazikika ndi zomangira zopanda kanthu za navicular. Kusamalidwa kunachitidwa kuti kuwonetsetse kuti mbali ya palmar ya fupa loyikidwayo ikugwedezeka ndi mbali ya palmar ya fupa la navicular kapena kuti yachepetsedwa pang'ono kuti kupewe kugwedezeka. Fluoroscopy idachitidwa kuti itsimikizire mawonekedwe a fupa la navicular, mzere wa mphamvu ndi malo a screw. Onani mtsempha wa vascular flap ku mbali ya mtsempha wa radial ndi mbali ndi nsonga ya venous ku mbali ya mtsempha wa radial wogwirizana ndi mtsempha kuchokera kumapeto (Chithunzi 8). Kapisozi yolumikizirana imakonzedwa, koma pedicle ya mitsempha yamagazi imapewedwa.
Chithunzi 8. Kuika fupa, kulimbika, ndi kufalikira kwa mitsempha yamagazi. Chipilala cha fupa chimayikidwa pang'onopang'ono m'dera la vuto la fupa la navicular ndikuchikonza ndi zomangira zopanda kanthu kapena ma pini a Kirschner. Samalani kuti malire a metacarpal a fupa loyikidwalo akhale osalala ndi malire a metacarpal a fupa la navicular kapena ochepetsedwa pang'ono kuti apewe kugwedezeka. Kufalikira kwa vascular flap artery kupita ku radial artery kunachitidwa kumapeto, ndipo nsonga ya mtsempha kupita ku radial artery yoyenderana nayo inachitidwa kumapeto.
Kubwezeretsa pambuyo pa opaleshoni
Aspirin womwa 325 mg patsiku (kwa mwezi umodzi), kunyamula kulemera kwa mwendo wokhudzidwa pambuyo pa opaleshoni kumaloledwa, kutsekereza bondo kungachepetse kusasangalala kwa wodwalayo, kutengera momwe wodwalayo angathe kusuntha panthawi yoyenera. Kuthandizira kwa ndodo imodzi kungachepetse ululu, koma kuthandizira ndodo kwa nthawi yayitali sikofunikira. Zosokerazo zinachotsedwa milungu iwiri pambuyo pa opaleshoni ndipo Muenster kapena kuponyedwa kwa mkono wautali kuchokera ku chala chachikulu kunasungidwa pamalo ake kwa milungu itatu. Pambuyo pake, kuponyedwa kwa mkono waufupi kuchokera ku chala chachikulu kumagwiritsidwa ntchito mpaka kuponyedwako kuchira. X-ray imatengedwa pakatha milungu itatu mpaka isanu ndi umodzi, ndipo kuchira kwa kuponyedwako kumatsimikiziridwa ndi CT. Pambuyo pake, zochita zolimbitsa thupi komanso zolimbitsa thupi ziyenera kuyambika pang'onopang'ono, ndipo mphamvu ndi kuchuluka kwa masewera olimbitsa thupi ziyenera kuwonjezeka pang'onopang'ono.
Mavuto akuluakulu
Mavuto akuluakulu a bondo ndi kupweteka kwa bondo kapena kuvulala kwa mitsempha. Kupweteka kwa bondo kumachitika makamaka mkati mwa milungu 6 mutachita opaleshoni, ndipo palibe kutayika kwa kumva kapena neuroma yopweteka chifukwa cha kuvulala kwa mitsempha ya saphenous komwe kunapezeka. Mavuto akuluakulu a dzanja anali kuphatikiza kusalumikizana kwa mafupa, kupweteka, kuuma kwa mafupa, kufooka, osteoarthritis yopita patsogolo ya dzanja la radial kapena mafupa a intercarpal, komanso chiopsezo cha periosteal heterotopic ossification chanenedwanso.
Kulumikiza Mafupa a Mitsempha ya ...
Nthawi yotumizira: Meyi-28-2024
