I. Selelekela
The distal humerus e na le litšiea tse bohareng le tse ka morao, tse kenyeletsang li-epicondyles le li-condyles.
II. Mokhoa oa ho Buoa
Ho robeha ha distal humerus ho bakoa ke ts'oaetso e tobileng (mohlala, ho oa) kapa matla a sa tobang (mohlala, ho sotha kapa ho hula mesifa).
III. Ho tsosolosa ka mor'a-op
AO classification e arola distal humerus fractures ka mefuta e meraro e meholo: A , B , le C .
IV. Liphetho tsa Thuto
Kalafo ea ho buuoa e latela melao-motheo ea AO: ho fokotseha ha anatomical, ho lokisoa ho tsitsitseng, le ho tsosolosoa pele.
V. Tlaleho ea Nyeoe
Lipoleiti tse notlelang li fana ka botsitso bo phahameng ba biomechanical, haholo-holo ho osteoporotic bone.
VI. Puisano
CZMEDITECH e fana ka mefuta e meraro: extraarticular (01.1107), lateral (5100-17), le lipoleiti tsa medial (5100-18).
VII. Qetello
Kalafo ea ho buuoa e latela melao-motheo ea AO: ho fokotseha ha anatomical, ho lokisoa ho tsitsitseng, le ho tsosolosoa pele.
Distal tibial fractures e tloaelehile, 'me phekolo ea setso e na le mefokolo
Distal tibial fractures ke mofuta o tloaelehileng oa ho robeha ha leoto le tlase. Liphekolo tsa setso tse kang lipoleiti tsa ho notlela le lipekere tsa antegrade intramedullary li na le mefokolo ea tsona. Lipoleiti tsa ho notlela li ka baka tšoaetso ea postoperative kapa necrosis ea lisele tse bonolo, ho lelefatsa ho hlaphoheloa; le hoja lipekere tsa antegrade li na le tšenyo e fokolang, li ka 'na tsa senya lenonyeletso la lengole, tsa baka bohloko,' me tsa jara likotsi tsa ho se lokisoe ka ho lekaneng kapa ho se sebetse hantle, ho sitisa ho hlaphoheloa.
Lipoleiti tsa ho notlela:
Tšenyo e kholo ea lisele tse bonolo, tekanyo e phahameng ea tšoaetso, ho hlaphoheloa nako e telele
Lipekere tsa Antegrade:
Kotsi ea kotsi ea lenonyeletso la lengole, ho lokisa ho sa lekaneng, ho atisa ho senyeha
Tharollo e ncha: Nail ea Distal Tibial (DTN)
Khetho e ncha ea phekolo-Distal Tibial Nail (DTN) -e fana ka pono e ncha ea ho laola fractures ea distal tibial ka moralo oa eona o ikhethang oa ho khutlela morao.
Moralo oa ho kenya retrograde o fana ka mokhoa o mocha
Boemo ba mokuli le ho itokisetsa ho fokotsa
Mokuli o behoa setulong sa supine. fractures displaced e lokela ho fokotsoa ka letsoho; ha ho hlokahala, sebelisa matla a phokotso ho thusa pele o kenya DTN. Haeba ho na le fracture e tsamaeang le fibula, ho tsamaisana ho nepahetseng ha fibula ho ka thusa ho fokotsa tibial. Ho robeha ha fibula shaft ho ka tsitsisoa ka lipekere tsa intramedullary. Bakeng sa fractures ho pota-potile leqaqailaneng, ho fokotseha ha anatomical le ho lokisoa ha fibula ho lokela ho etella pele ho fokotseha ha tibial ho qoba ho se lumellane. Likheong tse bulehileng tse nang le ho lokisa ka ntle, sepekere se ka kenngoa ha se ntse se boloka fixator ho finyella ho fokotseha.
Sebaka sa supine, sebelisa matla a ho fokotsa ha ho hlokahala
Beha pele tsamaiso ea fracture ea fibula ho netefatsa ho fokotseha ho nepahetseng ha tibial
Sekhahla sa bolelele ba 2-3 cm se etsoa ntlheng ea malleolus ea medial ho pepesa li-deltoid ligament e kaholimo. Pini ea tataiso e kenngoa ka hare kapa e bohareng hanyenyane ho ea fihla ntlheng ea malleolus (setšoantšo sa 2a), 4-5 mm ho tloha sebakeng sa articular. Pono ea morao-rao e bonts'a ho kenngoa ka groove ea intercondylar (setšoantšo sa 2b), ho qoba tšenyo ea mesifa ea posterior tibialis. Arola li-deltoid ligament e ka holimo-limo, ebe u sebelisa mochine oa ho tsosolosa ho atolosa mokokotlo oa medulla ho ea sebakeng sa metaphyseal (Setšoantšo sa 2c). Tlosa lesapo la cancellous haufi le proximal medial cortex ho kenya sepekere (setšoantšo sa 2d). Kenya sepekere sa teko ho netefatsa boholo ba DTN (Setšoantšo sa 2e). Qoba ho otla ka hamore kapa ho sotha ho feteletseng ho thibela ho robeha ha malleolar ea iatrogenic medial. Fetola botebo ba manala ho etsa bonnete ba hore li-screw tsa distal ha li kene lenonyeletsong la maqaqailana kapa sebaka sa ho robeha. Ho lokisoa ho finyelloa ka li-screws tse hokahaneng proximally le distal.
Sekoa:
Sekhao sa longitudinal ntlheng ea medial malleolus
Sebaka sa phini ea tataiso:
4-5 limilimithara ho tloha sebakeng se kopane
Ho bala le ho leka sepekere:
Ream ho fihlela metaphysis, netefatsa boholo ba manala
Ho kenya manala:
Qoba ho hammering, lokisa botebo ho sireletsa lenonyeletso
Tokiso:
Li-screws tse hokahaneng proximally le disally
Mokhoa oa ho kenya DTN
Ho tsamaea ha maqaqailaneng hang-hang le ho kopana ha maoto ho ea fatše ho lumelloa ka mor'a hore
ho be le boima ba 'mele bakeng sa libeke tsa 4-6
Ho hatela pele ho boima bo feletseng pakeng tsa libeke tsa 8-12, ha u ntse u shebile sebopeho sa callus le bohloko.Mosebetsi oa manonyeletso a maqaqailana o qala hang ka mor'a ho buuoa
Qoba ho jara boima ba 'mele bakeng sa libeke tse 4-6
Butle-butle phetoho ea boima bo feletseng ka libeke tse 8-12
Ho latela bakuli ba 10
Phuputso e ile ea latela bakuli ba 10 (Letlapa la 1). Ka mor'a likhoeli tse 3, linyeoe tse 7 li ne li folile; bakuli bohle ba fihletse pholiso nakong ea likhoeli tse 6. Ketsahalo e 'ngoe ea varus le recurvatum deformity e etsahetse. Ha ho tahlehelo ea phokotso, tšoaetso, mathata a amanang le ho kenngoa, kapa likotsi tsa iatrogenic tse ileng tsa bonoa (Letlapa la 2).
Linyeoe tse 7 li folile nakong ea likhoeli tse 3; kaofela li folile ka likhoeli tse 6
2 mefokolo e bobebe (1 varus, 1 recurvatum)
Ha ho ts'oaetso, mathata a kenngoeng, kapa tahlehelo ea phokotso
Mokuli e motona ea lilemo li 69
Mofuta oa ho robeha:
Transverse tibial fracture + fibular fracture
Bothata:
Leqeba la dinama tse bonolo
Phatlalatso:
Ke likheo tse nyane tse 6 feela, pholiso e felletseng nakong ea selemo se le seng
Lipalo 3 & 4:
Litšoantšo tsa ho hlaphoheloa ha radiographic le postoperative
Lipontšo tsa DTN
Thuto ena e kenyelelitse AO 43-A le C1 fractures; C2 le eona e ile ea shejoa. Li-DTN li fumaneha ka bolelele ba 7 mm le 8 mm, tse khethollang ho behoa ha li-screws tse pota-potileng. Maqhetsoana a fumanehang 2-9 cm ka holim'a bokaholimo ba marang-rang ke likhetho tse loketseng bakeng sa ho lokisa DTN. Matšoao a ka fetisetsoa ho fractures ea AO 42.
E sebetsa ho AO 43-A, C1, nahana ka ho holisa ho C2 le 42
Litholoana tse ntle ka ho fetisisa tsa fractures 2-9 cm ho tloha holim'a lenonyeletso
Botsitso ba Biomechanical
Lipekere tse khutlisetsang morao li na le boima bo phahameng ba axial le rotational ha bo bapisoa le lipoleiti tsa ho notlela tse bohareng le lipekere tsa antegrade. Greenfield le ba bang. e ile ea etsa tlhahlobo ea biomechanical e bontšang hore ho sebelisa li-screw tse peli tsa distal ho DTN ho fihletse 60-70% ea ho satalla ha khatello le 90% ea ho satalla ha torsional ha ho bapisoa le li-screw tse tharo. DTN e fokolitse motsamao oa sekhechana sa ho robeha tlas'a mojaro. Maemong a 3 a sa kang a fola nakong ea likhoeli tse 3, mabaka a ne a kenyelletsa tšenyo ea lisele tse bonolo, katoloso ea medulla, sebaka sa ho robeha, le lefu la ho fokola ha masapo. Kaha li-DTNs li tla ka boholo bo tharo feela 'me li-distal fixation li lekanyelitsoe ho li-screw tse tharo, li ka fana ka botsitso bo sa lekaneng likanaleng tse pharaletseng kapa osteoporotic bone. Ho jara boima ba pele ho lokela ho atameloa ka hloko maemong a joalo.
E phahame ho feta lipoleiti tsa ho notlela le lipekere tsa antegrade
Leano la ho lokisa le khothalelitsoeng: 2 proximal + 3 distal screws
Melemo ea DTN
Ha ho bapisoa le lipoleiti tsa ho notlela, lipekere tsa intramedullary li baka tšenyo e fokolang ea lisele tse bonolo, haholo-holo tse loketseng bakuli ba tsofetseng le ba nang le likotsi tse tebileng tsa lisele tse bonolo tse bakoang ke ts'oaetso e matla ea matla. Thutong ena, li-DTNs li kentsoe ka likheo tse nyane tse tšeletseng feela, ho se na mathata a lisele tse bonolo. Ts'ebetso ha e hloke hore lengole le fokotsehe, ho fokotsa kotsi ea ho fokotsa tahlehelo le ho etsa hore e tšoanele bakuli ba nang le mekhoa e fokolang ea lengole (mohlala, ramatiki ea lengole kapa post-TKA).
E hlasela ka mokhoa o fokolang, e loketse bakuli ba maqheku le ba nang le khatello e matla ea matla
Ha ho na ho feto-fetoha ha lengole ho hlokahalang, ho loketseng bakeng sa ho tsamaea ha lengole ho fokolang
Likotsi Tsa Ho Buoa le Litlhokomelo
Likotsi li kenyelletsa kotsi ho mesifa ea posterior tibialis le fracture ea malleolar e bohareng. Ho robeha ha malleolar ho ka alafshoa ka lithapo tsa tension band, plating, kapa ka ntle ho fixation.
Tlhokomelo e tlameha ho nkuoa ho qoba ho kenella ha screw ka har'a notch ea fibula. Sesebelisoa sa boemo se ka baka ho potoloha ka morao ha DTN ka lebaka la boima ba eona; lokisa sekoti sa bobeli ho supa ho fibula (setšoantšo sa 4c).Mathata a ka bang teng:
Kotsi ea posterior tibialis, ho robeha ha malleolar bohareng
Tsamaiso:
Tension band, plating, kapa fixator kantle
Screw direction le boemo ba boima ba sesebelisoa li hloka tlhokomelo ea ka hare ho opereishene
Papiso ea Clinical
Litefiso tsa ho se kopane le ho se lumellane ha lipekere tsa antegrade ke 0-25% le 8.3-50%, ka ho latellana; bakeng sa lipoleiti tsa ho notlela, 0–17% le 0–17%. Phuputsong ena, linyeoe tsohle li fihletse bonngoe, 'me ke 20% feela e neng e e-na le bokooa> 5 °, e bapisoang le mekhoa ea setso.Maemo a tšoaetso: tšoaetso e ka holimo ke 0-8.3% bakeng sa lipekere tsa antegrade le 0-23% bakeng sa lipoleiti tsa ho notlela; tšoaetso e tebileng ke 0-23% le 0-8.3%, ka ho latellana. Phuputso ena e tlalehile mathata a linama tse bonolo, ho feta mekhoa e 'meli e meng.Lintlha tse sebetsang:
Lintlha tsa AOFAS bakeng sa lipekere tsa antegrade: 86-88 (mofuta oa A), 73 (mofuta oa C); lipoleiti tse notlelang: 84–88 (mofuta oa A)
Thuto ena: AOFAS karolelano: 92.6
EQ-5D-5L: Lipoleiti tsa ho koala: 0.62-0.76; thuto ena: 0.876
SAFE-Q (bakuli ba maoto le maqaqailana): 67-75; thuto ena: 83–91.7 (Lethathamo la 3)
Sekhahla sa mekhatlo, sekhahla sa ho holofala, le sekhahla sa ts'oaetso li feta mekhoa e tloaelehileng
Lintlha tse sebetsang (AOFAS, EQ-5D-5L, SAFE-Q) li bonts'a liphetho tse ntle haholo
Ka kakaretso, DTN e fana ka melemo ho feta lipoleiti tsa ho notlela le lipekere tsa antegrade intramedullary 'me e emela tharollo e sebetsang bakeng sa ho phekola distal tibial fractures.
DTN e na le ts'oaetso e fokolang, botsitso bo phahameng, le ho hlaphoheloa ka potlako
Ke mokhoa o mong oa bohlokoa ho liphekolo tsa setso mme o lokela ho khothaletsoa
