Zvakadini kana kugadziriswa kwemukati kwe inter rotator fracture ikakundikana?

Hip fractures inofungidzirwa kukanganisa vanhu vakuru ve500,000 muUnited States gore negore. Vane simba guru pahutano hwehupenyu, parizvino vanoverengera 3-7% yevanofa muchipatara uye mwero wegore rimwe wekufa kwe19.4-58%. Inenge hafu yezvose zvakaputsika muhudyu ndeye intertrochanteric (IT) fractures. Iwo maviri anonyanya kuisirwa anoshandiswa kurapa IT kuputsika ndeye cephalomedullary nail (CMN) uye inotsvedza hudyu sikuru (SHS).

Pasinei nekufambira mberi mune teknolojia, kupera kwepfupa uye kukanganisa kwekugadzirisa zvakadai sekupinza musoro wemukadzi kuchiri kuitika uye kunogona kuparadza. Zvidzidzo zvenguva pfupi yapfuura zvakashuma mareti ekurasika anosvika 6% nemaimplants emazuva ano. Dambudziko rekugadzirisa kukanganisa kunosanganisira tip-tip kure (TAD)> 25 mm, kusakwana kwekuputsika kwekugadzirisa, kusagadzika maitiro ekuputsika, cephalic spikes inowanikwa kune rumwe rutivi kana pasi pepakati pemusoro wemukadzi, uye kutenderera kwemukati kwekervical stem angle. Kuchembera uye osteoporosis zvakare yakabatana nekutadza kugadzirisa.

Varwere uye Nzira

Iyi yaive ongororo yekudzokororwa kwevarwere vairapwa kuzvikoro zviviri zviri mukati mehutano hwehutano munzvimbo huru yedhorobha. Mhosva dzenyaya dzevavhiyi vaviri (JS neBC) dzakabvunzwa kune vese varwere vakagamuchira simende-yakasimbiswa revision gadziriso mushure mekutadza kwekutanga kugadziriswa kweIT yakaputsika kubva muna Ndira 2018 kusvika Gunyana 2021, mushure mekubvumidzwa nebhodhi rekuongorora. Kushandiswa kwesimbi yekusimbisa panguva yekuvhiyiwa kwekudzokorora kwakasimbiswa nerekodhi rekodhi rekodhi (EMR) kuongororwa kwezvinyorwa zvekushanda uye postoperative radiographs. Takabatanidza varwere vose vane zviratidzo zvekusimbiswa kwesimbi mukugadzirisa kugadzirisa mushure mekukundikana kwekutanga CMN kana SHS kugadzirisa kweIT fractures (Mufananidzo 1). Isu takabvisa varwere vane femoral mutsipa kana subtrochanteric fractures, varwere vasina kugadziridzwa kugadziriswa nesamende reinforcement, uye varwere vakawana arthroplasty panguva yekuvhiyiwa kwekutanga kwekudzokorora.

Mufananidzo 1. Mukadzi ane makore 76 ane makore ane makore ane 76 akaiswa intramedullary nailing ye intertrochanteric fracture ye femur (A), nekurwadziwa kwehudyu kunoramba kuripo 2 mwedzi gare gare nekuda kwekuisa incision (B).

Maitiro ekuvhiya

Kune varwere vanowana kugadzirisa kwekutanga neCMN, takaita yakagadziridzwa musoro chipikiri kutsiva uye bone simende kusimbisa. Pakutanga, 5-cm incision yakaitwa padivi peiyo trochanter yakakura, tambo yekutungamira yakaiswa mukati merutivi rwembambo, uye pfupa rose rakabviswa kubva parutivi rwembambo uchishandisa yakavhurika reamer. Zvadaro, hexagonal screwdriver yakashandiswa kusunungura screwation screw kumusoro kweCMN (Mufananidzo 2).

Mufananidzo 2, intraoperative fluoroscopy inoratidza hexagonal screwdriver ichiita uye kusunungura yakamboroverwa seti screw.

A 1-2 cm transverse incision inozoitwa pasi kuburikidza neiyootibial fascia (ITB) fascia. Iyo yepakutanga mbambo yemusoro inobviswa ine reverse threaded guide (Mufananidzo 3). Panyaya yekupedzwa kwemusoro wemukadzi, gwara rine buri rine distal Siruu yekukiya rinoshandiswa kudzivirira kubuda kwesamende mumubatanidzwa (Mufananidzo 3A). Kunyanya, iyo matrix yakatanga kubaiwa mushure mekubviswa kwezvikamu zviviri zvekunze zvekatatu kanula uye ndokuzoiswa munzvimbo ine perforated nekudzoreredza mativi maviri ekunze.

Mufananidzo 3, Intraoperative anteroposterior (A) uye lateral (B) mifananidzo yemumwe murwere anoratidza musoro wechikadzi ane interstitial bone defect graft.

Tevere, gumbo rinodhonzwa uye ipapo kuputsika kunoiswazve mune imwe exostosis yekudzokorora kugadzirisa. Muzviitiko zve malunion kana fibrous healing, percutaneous osteotomy inoshandiswa uchishandisa 1/4 'bone gouge ine anterolateral approach. Izvi hazviwanzodikanwa, asi zvinonyanya kushanda pazvinenge zvichidiwa kubudisa yakagadziridzwa cervical stem angle (target> 130 °).

Iyo screw itsva kana spiral blade inozoiswa mu subchondral bone mumusoro wechikadzi pamwe neaxis yehuro yemukadzi, kuve nechokwadi chekungwarira kusapinda mumusoro (Mufananidzo 4). Iyo screw inoiswa nemaune kunzvenga mbambo yakapfuura, asi ichiri kunongedzera kumagumo pakati pemusoro wemukadzi. (Mufananidzo 5)

Mufananidzo 4, Anteroposterior (A) uye lateral (B) mifananidzo yemumwe murwere anoratidza kuiswa kwekerfing tsono munzira yepikiri yemusoro mutsva.

Mufananidzo 5, intraoperative fluoroscopy inoratidza kuiswa kwetsva cephalomedullary blade padivi pegwara rewaya, iro rakazosimbiswa neseti screw.

Pakupedzisira, musoro wechikadzi unozadzwa nesamende yepfupa uchishandisa injectable bone simenti system (Mufananidzo 6). Kuchengetedza kunotorwa kuti udzivise extrusion mujoini nekushandisa chaiyo-nguva radiographs uye kugadzirisa kudzika uye kutaridzika kwecement cannula.

Mufananidzo 6, Kufananidzira kunoratidza kuwedzera simende pakutanga (A), kuzadza zvishoma nezvishoma (B) kusvikira chirema chemusoro chemukadzi chazadzwa (C).

Kune varwere vanowana kugadziriswa kwekutanga kweSHS, tinobvisa SHS uye tinoisa CMN yakareba. mushure mekuita 5-cm incision nechepakati pasi pe trochanter yakakura uye kuziva ITB, iyo incision inoparadzaniswa kusvika kune lateral plate. Ese maplate screws anobviswa uchishandisa akakodzera hand screwdriver uye lateral ndiro inobva yabviswa. Iwo tension screws anobva abviswa nereverse tambo gwara sezvakatsanangurwa kare kuti rimise pakatyoka kune imwe nhanho huru yevalgus. A 5-cm incision inozoitwa pamuromo wetrochanter yakakura sezvakatsanangurwa kare. Waya yegwara inoiswa kumucheto kwakaringana kwetrochanter hombe yoenda mberi mukati mehunde yemukadzi. Iyo yakavhurika reamer inounzwa munzira yeguidhiwire. Bhora refu-tipped guidewire rinobva raiswa pakati peiyo distal femur pazasi peyero yepatella. Tevere, kudzokororwa kunofambira mberi kwakaitwa kusvikira kudedera kwanzwika kumusana. Vese varwere vedu vakagamuchira CMN refu neTFN-ADVAN CE D (TFNa) proximal femoral intramedullary nailing system (DePuy- Synthes , Raynham, MA).

Kukurukurirana

Maitiro edu anoshandisa bone simenti kusimbisa panguva yekudzokorora kugadzirisa. Bone simenti yekusimbisa kwekutanga kugadziriswa kwe osteoporotic proximal femur fractures yakadzidzwa uye yakaratidza zvakanaka biomechanical uye kliniki migumisiro. Ongororo ichangoburwa yakashuma kuti pfupa simende kusimbiswa kwakakonzera mitoro yakakwira yekutadza, kuderedzwa kwekuisa implant displacement, uye kushomeka kwematambudziko uye mashandiro akaenzaniswa nekusasimbisa kugadzirisa. A randomized, multicenter tarisiro yekudzidza yakashumawo kuti hapana kudzokororwa kana zviratidzo zveCMN kutamiswa muboka rakasimbiswa-simende zvichienzaniswa nematare matanhatu muboka risina kusimbiswa.

Hp fracture kufa kwakakwira. Zvidzidzo zvenguva pfupi yapfuura zvakatsanangura 3-7% yekufa muchipatara, uye kufa kwegore rimwe kunoderera kubva pa19.4% kusvika 58%. Kunyanya, kutsemuka kweIT kwakaratidzwa kuverengera 27% yekufa kwegore rimwe. Makiriniki edu akatevedzana haana kuratidza kufa muchipatara uye gore rimwe chete rekufa kwe13.6%, iyo yakaderera kana ichienzaniswa nemabhuku. Nekuti kufamba kwemubhedha kwekutanga mushure mekuvhiyiwa kwakabatana nekufa kwakaderera, kubhururuka kwakanaka uye mhedzisiro inoshanda munhevedzano yedu inogona kutsanangura kufa kwakaderera kunoonekwa muvarwere vedu.

Mhedziso

Cement-reinforced revision fixation inzira inobudirira, yakachengeteka, uye inodhura ye-non-infected intertrochanteric fracture fixation kukundikana kune vakwegura vane acetabular bone stock yakakwana.

Varwere vakakundikana kugadzirisa kwepakati pekutanga intertrochanteric fractures inoteverwa nekudzokorora kugadzirisa uye simenti-yakasimbiswa kurapwa vakaratidza zvakanaka zvenguva refu kliniki uye mararamiro ehupenyu. Nzira yacho yakashandiswa chete mumamiriro ezvinhu apo iyo yakawanda yeacetabular articular surface yakachengetedzwa uye musoro wembambo wakaramba uri mukati memutsipa wechikadzi. Tichifunga nezvekugumira kwekudzokorora arthroplasty muvarwere vakura vasina simba, maitiro aya anoratidza kuvimbiswa mukuchengetedza zvakachengeteka uye zvinobudirira kuderedza matambudziko akakomba nekuderedza nguva yekushanda uye mutengo muboka iri revarwere.

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