Kuphulika kwa khosi lachikazi ndi chimodzi mwa zovulala za mafupa zomwe zimachitika kawirikawiri m'chipatala, ndipo ambiri mwa odwala okalamba amawerengera oposa 50% a kuphulika kwa chiuno. Malingana ndi ziwerengero, chiwerengero cha kuphulika kwa khosi lachikazi chawonjezeka pang'onopang'ono m'zaka zaposachedwapa, ndi chiwerengero chachikulu cha amayi kusiyana ndi amuna. Vertigo, dementia, malignancy ndi cardiopulmonary matenda mwa okalamba ndi kuvulala kwamphamvu kwa achinyamata ndizomwe zimakhala zoopsa kwambiri chifukwa cha kuphulika kwa khosi lachikazi.
M'zaka zaposachedwa, zida zambiri zomangira mkati monga zomangira zosabowola, zomangira zamphamvu za m'chiuno (DHS), zomangira za m'chiuno (HSH), mbale zophatikizira zachikazi, misomali yomanganso, ndi misomali ya Gamma zatulukira. Pakati pazida zokonzera mkatizi, zomangira zopanda pake ndizo zomwe zimagwiritsidwa ntchito kwambiri. Kafukufuku wasonyeza kuti ambiri mwa maopaleshoni amakonda zomangira zopanda kanthu pochiza ming'alu yopanda malo, ndipo ambiri mwa maopaleshoni amasankha kugwiritsa ntchito zomangira zopanda kanthu pothyoka khosi lachikazi. 3 yolumikizira pang'ono phula wononga wononga ndi njira yovomerezeka kwambiri yolumikizira mkati.
Mawonekedwe a anatomical a femoral khosi fractures
Tsopano amavomereza kuti mitsempha ya mutu wa chikazi ndi chinthu chofunika kwambiri chomwe chimakhudza machiritso a fracture ndi femoral mutu necrosis. Kuwonongeka kwa mapangidwe a magazi a mutu wachikazi ndiye chinthu chachikulu cha pathological cha ischemic necrosis ya mutu wachikazi. Kufufuza mwadongosolo kwa mitsempha ya mitsempha ya khosi lachikazi kunapeza kuti epiphyseal vascular network ndi arterial system of the inferior zone yothandizira zingakhale zofunikira kuti magazi azikhala ndi magazi kumutu wa chikazi pambuyo pa kusweka kwa khosi lachikazi, kotero kuti kubowola kwa intraoperative ndi implantation pafupi ndi momwe kungathekere kudera lapakati la chikazi kungathandize kuchepetsa kuvulala kwa mutu wa chikazi. intraosseous vascular system.
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Chithunzi 1 Kupereka magazi kumutu wa femoral, anterolateral (a) ndi mawonedwe ambuyo (b). Pali kusiyana kwa magazi kumutu wa chikazi, koma mitsempha yotsalira ndi yapakati ya spinofemoral imachokera ku mitsempha yakuya yachikazi mu 60% ya odwala.
(1) Magazi ambiri kumutu wa chikazi amachokera ku lateral rotor femoral artery.
(2) Imatulutsa nthambi zitatu kapena zinayi zomwe zimachirikiza mtsempha wa chingwe. Nthambizi zimayenda cham'mbuyo ndi m'mwamba pamodzi ndi retroflexed gawo la synovial khosi la femur kwa cartilaginous m'mphepete mwa chikazi mutu. Ziwiya mkati mwa ligament yozungulira.
(3) Wochokera ku mtsempha wa foramen occulta. Nthambi yokwera ya mtsempha wapakati wa rotor femoral.
(4) Amapereka trochanter yaikulu ya femur ndikupanga mphete yamagazi ndi lateral rotor femoral artery.
Zomangira zopanda pake za kuthyoka kwa khosi lachikazi
Zachipatala, zomangira zitatu zopanda pake za mafupa a 6.5 mm kapena 7.0 mm kapena 7.3 mm zitha kugwiritsidwa ntchito pokonza odwala achichepere kapena azaka zapakati kapena akulu omwe ali ndi mafupa abwino. Cholozera chiyenera kuikidwa kuti misomali itatu yobowoka ikhale yofanana kuti misomali yophwanyika igwedezeke. Mkati mwa khosi lachikazi, zomangirazo ziyenera kuponyedwa m'mphepete mwake, ndikusamala kuti zomangirazo zilowetsedwe kumutu wa chikazi osati kudutsa mzere wosweka, chifukwa iyi ndiyo njira yokhayo yopezera kuponderezedwa kwapakati. Zomangirazo ziyenera kumangika ndikutsimikiziridwa mobwerezabwereza intraoperative. Ngati bedi lokokera likugwiritsidwa ntchito, kukokerako kuyenera kumasuka. Zomangira zopanda pake zimathanso kuyikidwa molunjika. Frontal, lateral, ndi 45 ° oblique fluoroscopy iyenera kuchitidwa kuti zitsimikizidwe kuti zomangira zisalowe m'chiuno.
1, Njira zapadera za opaleshoni.
Tengani 'inverted triangle' kuyika kwa misomali, komwe kumagwiritsidwa ntchito kwambiri m'chipatala, mwachitsanzo.
a. Choyamba, pansi pa fluoroscopy, ntchito X-ray mu ndege ziwiri za fluoroscopy kudziwa masanjidwe a m'munsi ndi pakati kalozera zikhomo.
b. Kudula khungu kumapangidwa komwe kumatalikirana ndi 2-3 cm.
c. Fascial wosanjikiza amasiyanitsidwa pamodzi ndi incision ndipo cholekanitsa cha Cobb chimagwiritsidwa ntchito kulekanitsa ulusi wautali womwe umagwirizana ndi lateral minofu yachikazi.
d. Ikani singano yolondolera pamalo pomwe ndege zonse zili zangwiro.
e. Pini yolondolera imodzi inayikidwa cham'mbali mwa khosi lachikazi ndi wothandizira kuti adziwe mbali yakunja yopendekeka.
f. Pambuyo pokonza pini yoyamba yotsogolera, mapepala otsogolera a posterosuperior ndi anterosuperior amadziwika pogwiritsa ntchito maulamuliro ofanana kuti apeze chithandizo cham'mbuyo ndi cham'mbuyo cha cortical mkati mwa khosi lachikazi.
g. Izi zimachitika mwa kuyika pini yowongolera pamwamba pa trochanter yocheperako pamodzi ndi distal femoral neck cortex kudzera pa msana wa femoral; zikhomo ziwiri zotsatila zimayikidwa moyandikana, motalika momwe zingathere ndi 5 mm kuchokera kutsogolo ndi kumbuyo; kuya kwa pini yowongolera kumasinthidwa kuti ifike 5 mm pansi pa chichereŵechereŵe; Pomaliza, dzenjelo limasinthidwanso, kuyezedwa, ndipo phula lopanikizidwa lotsekeka limalowetsedwamo.
h. Onetsetsani kuti musalowe mu singano pansi pa trochanter yaing'ono ndikuyenda pafupi ndi msana wa femoral.
ndi. Onetsetsani kuti pini ya ulusi yaikidwa pansi pa olowa.
j. Musalole pini yolondolera kulowa pamtunda.
k. Dziwani kutalika kwa wononga koyenera poyeza kutalika kwa pini ya kalozera kenako ndikuchotsa 5 mm.
l. Nthawi zambiri zomangira zokha, zomangira zodzibowolera zimagwiritsidwa ntchito, koma nthawi zina zisanachitike kubowola kwa lateral cortex kumafunika kwa odwala okhulupirika omwe ali ndi fupa lakuda.
m. Ngati danga likuloleza, spacer ingagwiritsidwe ntchito.
n. 4th screw (makonzedwe a diamondi) atha kukhala ofunikira kwa okhulupilika omwe ali ndi zosweka kwambiri zakumbuyo kwa dzanja.
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Ngakhale zomangira zopanda pake za kuthyoka kwa khosi lachikazi ndizofala kwambiri, pamakhalabe kusiyana kwa malingaliro okhudzana ndi kuchuluka ndi masinthidwe a zomangira zomwe zaikidwa pa opaleshoni, nthawi zambiri kutengera zomwe wogwiritsa ntchito amakonda; zinthu monga kachulukidwe mafupa a wodwalayo, wononga mphamvu, ndi kupambana kwa mankhwala zimathandizanso.
1, Chiwerengero cha zomangira dzenje.
Kuphulika kwa khosi lachikazi nthawi zambiri kumakonzedwa ndi 2-4 zomangira zopanda kanthu.
Nthawi zambiri, zomangira za 3 zimagwiritsidwa ntchito chifukwa zimatha kupirira kupsinjika kolimba kwam'mbuyo, kukulitsa kukhazikika, ndikuchepetsa kusuntha kwa fracture.
Kwa kusweka kwa khosi lachikazi ndi Pauwells angle> 50 °, zomangira 2 ndizomveka.
Odwala omwe amathyoka kwambiri khosi lachikazi la posterior, zomangira 4 zopanda pake zalimbikitsidwa.
Komabe, mchitidwe womwe udalipobe ndikugwiritsabe ntchito zomangira 3 zopanda pake pokonza.
2, Kukonzekera kwa wononga zakuya.
Pamene 3 zomangira dzenje ntchito kukonza mkati mwa femoral kuthyoka kwa khosi, amakhulupirira kuti chiphunzitso cha 'kutsetsereka psinjika' ayenera kutsatiridwa, kotero kuti 3 zomangira wobzalidwa ndi kufanana wina ndi mzake mu orthogonal view ndi kukhala ndi kasinthidwe triangular mu lateral view.
Mwanjira iyi, zomangira zitatu zofananira zopanda pake zimatha kupereka chithandizo chabwino chamakina ndikupanga njira yotsetsereka, kotero kuti chipika chophwanyika chikhoza kuyendayenda pakhosi lachikazi pansi pa kugwedeza kwa minofu ya m'chiuno, kupanga kupanikizika kumapeto kwa fracture ndi kulimbikitsa machiritso a fracture.
Komabe, ngati zomangira 3 zosabowola zayalidwa mu orthotriangular kapena inverted triangular configuration zakhala zotsutsana.
Kutsogola kwa hollow screw fixation pakuphwanya khosi lachikazi
Yuenyongviwat et al. anakonza latsopano chosinthika kufanana pobowola kalozera kuyika kwa zomangira dzenje pochiza chikazi khosi fractures ndi fixation mkati, ndipo anapeza kuti kalozera watsopanoyu akhoza kuchepetsa ntchito nthawi ndi chiwerengero cha intraoperative fluoroscopic maganizo poyerekeza ndi chikhalidwe njira, motero kupeza zotsatira zogwira mtima opaleshoni.
Filipov ndi al. adapanga biplane kawiri-anathandiza wononga fixation (BDSF), imene polowera mfundo zomangira atatu dzenje ili mu wandiweyani kotekisi m'dera la proximal femoral tsinde, ndi zomangira atatu ndi wogawana kuchepetsa kwa periphery mutu wa chikazi, motero kupanga ndege ziwiri. Njirayi imalola chithandizo chambiri cha cortical, motero kupereka mphamvu zokwanira zokonzekera panthawi yoyenda.
Kuyesera kwa biomechanical pogwiritsa ntchito zitsanzo za cadaveric kunasonyeza kuti njira yokonzekera ya BDSF imapereka njira yabwinoko kuposa njira yachikhalidwe yosinthira makona atatu. Zotsatira za kuyesa kwa biomechanical pogwiritsa ntchito zitsanzo za cadaveric kunasonyeza kuti simenti ya calcium phosphate yolimbitsa misala yokhotakhota imathandizira kwambiri kukhazikika kwa wononga phula la khosi lachikazi, kumapangitsa kuti khosi la chikazi likhale lolimba, komanso kulimba kwa torsional, komwe kuli kothandiza kwambiri pachipatala.
Chifukwa cha kuthekera kwakukulu kwa mutu wa femoral necrosis pambuyo pa kukhazikika kwa misomali yopanda pake chifukwa cha kuthyoka kwa khosi lachikazi, njira zina zakhala zikugwiritsidwa ntchito mosalekeza kuthandiza kukonza mkati mwa msomali kuti muchepetse zovuta monga femoral mutu necrosis. Choyambitsa cha femoral mutu necrosis pambuyo pa kusweka kwa khosi lachikazi ndikutaya kwa magazi kupita kumutu wa chikazi, ndiye cholinga cha chithandizo ndi momwe mungayendetsere magazi. Kukhazikitsidwa kwa magazi opangidwa ndi periosteum kumezanitsa m'dera la necrotic la mutu wa chikazi ndi kudzazidwa kwakunja kwa zotsalira zotsalira ndi zosanjikiza zomwe zimamera zidzathandiza kusiyanitsa kwa periosteum yomezanitsidwa mu osteoblasts komanso kusinthika kwa mitsempha ya mitsempha, yomwe imakhala ndi zotsatira za osteogenic ndi revascularization.
Chidule
Hollow screw fixation kwa femoral khosi fracture ndi njira yothandiza kwambiri yokonza, yomwe ili ndi ubwino wa ntchito yosavuta, nthawi yochepa ya opaleshoni, kupwetekedwa pang'ono, kukhazikika kodalirika komanso kuchira msanga pambuyo pa opaleshoni. Komabe, chifukwa cha anatomical makhalidwe a femoral khosi fractures, mavuto a ischemic necrosis a chikazi mutu ndi sanali mgwirizano wa fracture sangathe kupeŵa kwathunthu ndi fixation mkati kwa femoral khosi fractures. Choncho, zizindikiro zogwiritsira ntchito njira yokonzekerayi ziyenera kufotokozedwa bwino musanagwiritse ntchito, ndipo odwala okalamba omwe ali ndi khosi lachikazi losamuka kwambiri komanso chikhalidwe chosauka chomwe chimafuna ntchito yoyambirira ayenera kupewa kugwiritsa ntchito kukonzanso mkati kwa khosi lachikazi momwe zingathere. Zowopsa zomwe zimakhudza momwe wodwalayo alili, monga mtundu wa fracture, kuchulukitsidwa kwa mafupa, ndi momwe wodwalayo amagwirira ntchito, ziyeneranso kuganiziridwa kuti zichepetse zovuta zomwe zimakhalapo kwa nthawi yayitali ndipo motero kupititsa patsogolo zotsatira za chithandizo cha kuphulika kwa khosi lachikazi.
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