I-Femoral neck fracture yenye yezona zinto zixhaphakileyo ezijongene nokulimala kwamathambo kwiklinikhi, kunye neninzi yezigulane ezisebekhulile ezibalelwa ngaphezu kwe-50% ye-hip fractures. Ngokwezibalo, iziganeko zokuqhekeka kwentamo ye-femoral ziye zanda ngokuthe ngcembe kwiminyaka yamuva nje, kunye nesiganeko esiphezulu kwabasetyhini kunamadoda. I-Vertigo, i-dementia, i-malignancy kunye nesifo se-cardiopulmonary kubantu abadala kunye nokulimala kwamandla aphezulu kubantu abatsha zizinto ezinobungozi obuphezulu bokuphuka kwentamo ye-femal.
Kwiminyaka yakutshanje, izinto ezininzi zokulungiswa kwangaphakathi ezifana nezikhonkwane ezingenanto, izikhonkwane ze-hip zamandla (DHS), i-sliding hip screws (HSH), iipleyiti ze-femoral dissection plates, izikhonkwane zokwakhiwa ngokutsha, kunye nezikhonkwane ze-Gamma ziye zavela. Phakathi kwezi zixhobo zokulungiswa kwangaphakathi, izikhonkwane ezingenanto zisetyenziswa ngokuqhelekileyo. Uphononongo lubonise ukuba uninzi loogqirha botyando bakhetha izikrufu ezingenanto kunyango lwezaphukileyo ezingenandawo, kwaye uninzi loogqirha botyando bakhetha ukusebenzisa izikrufu ezingenanto zokwaphuka kwentamo yebhinqa. I-3 edityanisiweyo edityaniswe ngokungagqibelelanga isikhonkwane solungiso lolona hlobo olwamkelwe ngakumbi lolungiso lwangaphakathi.
Iimpawu ze-anatomical zokuphulwa kwentamo ye-femal
Ngoku kuyamkelwa ngokubanzi ukuba i-vascular structure yentloko ye-femoral iyona nto ibaluleke kakhulu echaphazela ukuphulukiswa kwe-fracture kunye ne-necrosis yentloko ye-femal. Ukonakaliswa kwezakhiwo zonikezelo lwegazi lwentloko ye-femoral iyona nto iphambili ye-pathological factor ye-ischemic necrosis yentloko ye-femoral. Uphononongo olucwangcisiweyo lwe-vascular anatomy yentamo ye-femoral lufumene ukuba i-epiphyseal vascular network kunye ne-arterial system ye-inferior zone yokuxhasa ingaba zakhiwo ezibalulekileyo zokugcina igazi kwintloko yesifazane emva kokuphuka kwentamo ye-femoral, ukwenzela ukuba u-intraoperative drilling kunye nokufakelwa ngokusondeleyo kangangoko kunokwenzeka kwingingqi ephakathi kwentloko ye-femoral inokunciphisa ngokufanelekileyo ukwenzakala kwintloko ye-femoral. inkqubo yemithambo ye-intraosseous.
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Umzobo 1 Ukunikezelwa kwegazi kwintloko ye-femal, i-anterolateral (a) kunye ne-posterior (b) imibono. Kukho ukuhluka kwegazi kwintloko ye-femoral, kodwa i-lateral and medial spinofemoral arteries ivela kwi-artery deep femoral kwi-60% yezigulane.
(1) Uninzi lonikezelo lwegazi kwintloko ye-femoral luvela kwi-lateral rotor femoral artery.
(2) Ikhupha amasebe ama-3 okanye ama-4 axhasa umthambo womtya. La masebe ahamba ngasemva nangaphezulu kunye nenxalenye ye-retroflexed yentamo ye-synovial ye-femur ukuya kumda we-cartilaginous wentloko ye-femoral. Iinqanawa ngaphakathi kwe-ligament ejikelezayo.
(3) Ithathwe kwi-foramen occulta artery. Isebe elinyukayo le-medial rotor femoral artery.
(4) Ibonelela nge-trochanter enkulu ye-femur kwaye yenza i-arterial ring kunye ne-lateral rotor femoral artery.
Izikrufu ezingenanto zokwaphuka kwentamo ye-femoral
Ngokoklinikhi, izikrufu ezintathu zamathambo eziyi-6.5 mm okanye 7.0 mm okanye 7.3 mm zingasetyenziselwa ukulungiswa kwizigulana eziselula okanye kwizigulana ezikubudala obuphakathi okanye abadala ezinomgangatho olungileyo wamathambo. Isikhokelo kufuneka sisetyenziswe ukugcina izikhonkwane ezi-3 ezingenanto zihambelana ukuvumela ukunyanzeliswa kwe-sliding fracture. Ngaphakathi kwentamo ye-femoral, izikrufu kufuneka zifakwe kwimiphetho, unakekele ukuba izikhonkwane zifakwe kwintloko ye-femoral kwaye kungekhona ngaphesheya komgca wokuphuka, njengoko le yindlela yodwa yokufumana ukunyanzeliswa kwe-inter-end. Izikhonkwane kufuneka ziqiniswe kwaye ziqinisekiswe ngokuphindaphindiweyo kwi-intraoperatively. Ukuba ibhedi yokutsala isetyenzisiwe, ukutsala kufuneka kukhululeke. Izikrufu eziHollow nazo zinokubekwa kwi-percutaneously. Ngaphambili, ecaleni, kunye ne-45 ° oblique fluoroscopy kufuneka yenziwe ukuze kuqinisekiswe ukuba izikrufu azingeni kwi-joint hip.
1. Iindlela zotyando ezikhethekileyo.
Thatha 'unxantathu ojikisiweyo' wokubekwa kwezikhonkwane, osetyenziswa ngokuqhelekileyo kuqheliselo lwezonyango, njengomzekelo.
a. Okokuqala, phantsi kwe-fluoroscopy, sebenzisa i-X-ray kwiindiza ezimbini ze-fluoroscopy ukumisela ukucwangciswa kwezikhonkwane ezisezantsi kunye neziphakathi.
b. Kwenziwa i-skin incision eyandisa i-2-3 cm ngokusondeleyo.
c. Umaleko we-fascial uhlukaniswe kunye ne-incision kwaye i-Cobb separator isetyenziselwa ukwahlula iintambo ze-longitudinal kunye ne-lateral femoral muscle.
d. Beka inaliti yesikhokelo kwindawo apho zombini iindiza zigqibelele.
e. Esinye isikhonkwane sesikhokelo sasibekwe ecaleni kwendawo yangaphambili yentamo ye-femoral kunye nomncedisi wokugqiba i-angle yokuthambeka yangaphambili.
f. Emva kokulungiswa kwepini yesikhokelo sokuqala, izikhonkwane ze-posterosuperior kunye ne-anterosuperior zesikhokelo zichongiwe ngokusebenzisa izikhokelo ezihambelanayo zokufumana inkxaso ye-cortical yangasemva kunye ne-anterior ngaphakathi kwentamo ye-femoral.
g. Oku kwenziwa ngokufaka ipini yesikhokelo ngaphezu kwe-trochanter encinci ecaleni kwe-distal femoral neck cortex nge-femoral spine; izikhonkwane ezimbini ezilandelayo zifakwe ngokusondeleyo ngendlela ehambelanayo, ngokude kangangoko kunokwenzeka kunye ne-5 mm ukusuka kwi-cortex yangaphambili kunye ne-posterior; ubunzulu bokungena kwepini yesikhokelo ke kulungelelaniswa ukufikelela kwi-5 mm ngaphantsi kwe-cartilage; ekugqibeleni, umngxuma remed, kulinganiswe, kwaye isikrufu umngxunya olucinezelekileyo is screwed in.
h. Qinisekisa ukuba ungangeni inaliti engaphantsi kwe-trochanter encinci kwaye uhambe ngokusondeleyo kwi-femoral spine.
i. Qinisekisa ukuba isikhonkwane sesikhokelo esinemisonto sibekwe ngaphantsi kwendawo edibeneyo.
j. Musa ukuvumela ipini yesikhokelo ukuba ingene kwindawo ye-articular.
k. Gqiba ubude be-screw obufanelekileyo ngokulinganisa ubude besikhonkwane sesikhokelo uze ususe i-5 mm.
l. Ngokuqhelekileyo, ukuzicofa, izikrufu zokuzibhola ziyasetyenziswa, kodwa ngamanye amaxesha ukugrunjwa kwangaphambili kwe-cortex esecaleni kuyafuneka kwizigulana ezithembekileyo ezinethambo elingqindilili.
m. Ukuba isithuba siyavuma, kunokusetyenziswa isiphekepheke.
n. I-screw yesi-4 (ulungiselelo lwedayimane) lunokuba luyimfuneko kubathembekileyo abaneefractures ezinzima ze-posterior yesandla.
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Nangona izikrufu ezingenanto zokwaphuka kwentamo ye-femoral ngoku zixhaphake kakhulu, kusekho iiyantlukwano zoluvo malunga nenani kunye nolungelelwaniso lwezikrufu ezibekwe ngotyando ezihollow, ngokwesiqhelo kuxhomekeka kukhetho lomqhubi; Izinto ezifana nokuxinana kwethambo lesigulana, ukomelela kwezikrufu, kunye nempumelelo yonyango nazo zinefuthe.
1, Inani lezikhonkwane ezingenanto.
Iifractures zentamo ye-Femoral zivame ukulungiswa kunye ne-2-4 izikhonkwane ezingenanto.
Kwiimeko ezininzi, ii-screws ezi-3 zisetyenziselwa ngenxa yokuba ziyakwazi ukumelana noxinzelelo olunamandla lwangaphambili, ukwandisa ukuzinza, kunye nokunciphisa ukufuduka kokuphela kwe-fracture.
Ngokwaphuka kwentamo ye-femoral nge-angle ye-Pauwells>50 °, izikrufu ezi-2 zisengqiqweni ngakumbi.
Kwizigulana ezinobunzima obunzima bokuphuka kwentamo ye-femoral ye-posterior, i-screws e-4 engenanto iye yakhuthazwa.
Nangona kunjalo, isenzo esikhoyo kusekukusebenzisa izikrufu ezi-3 ezingenanto zokulungiswa.
2, Uqwalaselo lwe-screw engenanto.
Xa izikrufu ezi-3 ezihollow zisetyenziselwa ukulungiswa kwangaphakathi kokuqhekeka kwentamo ye-femoral, kukholelwa ngokubanzi ukuba ithiyori 'yokunyanzeliswa kwesilayidi' kufuneka ilandelwe, ukuze izikrufu ezi-3 ezihlonyelweyo zihambelane enye kwenye kumbono we-orthogonal kwaye zibe noqwalaselo lwe-triangular kumbono osecaleni.
Ngale ndlela, i-screws ezintathu ezihambelanayo ezilinganayo ziyakwazi ukubonelela ngenkxaso efanelekileyo yomatshini kwaye zenze umkhondo wokutyibilika, ukwenzela ukuba ibhloko ye-fracture ikwazi ukuslayida ecaleni kwe-axis yentamo ye-femoral phantsi kokunyanzeliswa kwemisipha ye-hip, ukudala uxinzelelo ekupheleni kokuphuka kunye nokukhuthaza ukuphulukiswa kwe-fracture.
Nangona kunjalo, nokuba izikrufu ezi-3 ezihollow zibekwe kwi-orthotriangular okanye kubumbeko obujikisiweyo obunxantathu iye yaba yimpikiswano.
Ukuqhubela phambili kubuchule bokulungisa izikrufu ezingenanto zokwaphuka kwentamo yefemoral
Yuenyongviwat et al. yenzelwe isikhokelo esitsha sokomba esilungelelanisiweyo sokubekwa kwezikrufu ezingenanto kunyango lwezahlulo zentamo ye-femoral ngokulungiswa kwangaphakathi, kwaye yafumanisa ukuba esi sikhokelo esitsha sinokunciphisa ixesha lokusebenza kunye nenani leembono ze-intraoperative fluoroscopic xa kuthelekiswa nendlela yendabuko, ngaloo ndlela ifumana iziphumo zotyando ezanelisayo.
UFilipov et al. yenzelwe i-biplane exhaswa kabini ngokulungiswa kwe-screw (BDSF), apho indawo yokungena yezikrufu ezintathu egobileyo ibekwe kwindawo eshinyeneyo yecortical ye-proximal femoral stem, kunye nezikrufu ezithathu zilungelelaniswe ngokulinganayo kwi-periphery yentloko ye-femoral, ngaloo ndlela zenza iinqwelomoya ezimbini. Le ndlela ivumela ukuxhaswa kwe-cortical kabini, ngaloo ndlela inika amandla okulungisa okwaneleyo ngexesha lokunyakaza.
Iimvavanyo ze-Biomechanical zisebenzisa i-cadaveric specimens zibonise ukuba indlela yokulungiswa kwe-BDSF inikezela ukulungiswa okungcono kunendlela yendabuko yokulungisa unxantathu. Iziphumo zovavanyo lwe-biomechanical kusetyenziswa imizekelo ye-cadaveric zibonise ukuba i-calcium phosphate sement eyomeleziweyo isikrufu sokulungiswa komngxunya iphucule ngokuphawulekayo uzinzo lwe-screw fixation ye-femoral neck fractures, yandisa ukunyanzeliswa kwentamo ye-femoral, kunye nokuphucula ukuqina kwe-torsional, okubaluleke kakhulu kwezonyango.
Ngenxa yokuba nokwenzeka okuphezulu kwe-femoral head necrosis emva kokulungiswa kwesikhonkwane esingenanto kwi-femoral neck fractures, ezinye iindlela ziye zasetyenziswa ngokuqhubekayo ukuncedisa ukulungiswa kwangaphakathi kwesikhonkwane ukunciphisa iingxaki ezifana ne-femoral head necrosis. Ingcambu ye-femoral necrosis ye-femoral necrosis emva kokuphuka kwentamo ye-femoral kukulahleka kwegazi kwintloko ye-femal, ngoko ke kugxininiso lonyango yindlela yokuphucula ukuhamba kwegazi. Ukuqaliswa kwe-periosteum ebonelelwe ngegazi kwindawo ye-necrotic yentloko ye-femoral kunye nokuzaliswa kwangaphandle kwendawo eseleyo ngumgca wokuhluma kuya kunceda ukuhlukana kwe-periosteum edibeneyo kwi-osteoblasts kunye nokuhlaziywa kwe-vascular sprouts, ene-osteogenic ne-revascular effects.
Isishwankathelo
Ukulungiswa kwe-screw ye-Hollow ye-femoral neck fracture yindlela efanelekileyo kakhulu yokulungisa, enenzuzo yokusebenza okulula, ixesha elifutshane lokusebenza, ukwenzakala okuncinci, ukulungiswa okuthembekileyo kunye nokubuyisela ngokukhawuleza emva kokuhlinzwa. Nangona kunjalo, ngenxa yeempawu ze-anatomical ze-femoral neck fractures, iingxaki ze-ischemic necrosis yentloko ye-femoral kunye ne-non-union of the fracture ayinakuphetshwa ngokupheleleyo ngokulungiswa kwangaphakathi kwi-neck fractures yentamo. Ngoko ke, izibonakaliso zokusetyenziswa kwale ndlela yokulungiswa kufuneka zicaciswe ngaphambi kokusetyenziswa, kunye nezigulane ezisebekhulile ezineentambo zentamo ye-femoral ezifudukayo kunye nesimo esibi ngokubanzi esifuna umsebenzi wokuqala kufuneka sigweme ukusebenzisa ukulungiswa kwangaphakathi kwi-femoral neck fractures kangangoko kunokwenzeka. Izinto ezinobungozi ezichaphazela ukuxilongwa kwesigulane, ezifana nohlobo lokuphuka, ukuxinana kwamathambo, kunye nesimo sokusebenza kwesigulane, kufuneka kwakhona kuthathelwe ingqalelo ukunciphisa iingxaki zexesha elide emva kokuhlinzwa kwaye ngaloo ndlela kuphuculwe umphumo wonyango wokuphulwa kwentamo ye-femal.
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