I. Intshayelelo
I-distal humerus iqukethe iikholomu zangaphakathi kunye necala, ezibandakanya i-epicondyles kunye ne-condyles.
II. Inkqubo yoTyando
Ukuqhekeka kwe-distal humerus kubangelwa kukwenzakala ngokuthe ngqo (umzekelo, ukuwa) okanye amandla angathanga ngqo (umzekelo, ukujija okanye ukutsalwa kwezihlunu).
III. Ukubuyisela kwimo yesiqhelo emva kokuphuma
Uluhlu lwe-AO luhlula i-distal humerus fractures kwiintlobo ezintathu eziphambili: A, B, kunye noC.
IV. Iziphumo zoFundo
Unyango lotyando lulandela imigaqo ye-AO: ukunciphisa i-anatomical, ukulungiswa okuzinzile, kunye nokuvuselelwa kwangaphambili.
V. Ingxelo yeCase
Iipleyiti zokutshixa zinika uzinzo oluphezulu lwe-biomechanical, ngakumbi kwithambo le-osteoporotic.
VI. Ingxoxo
I-CZMEDITECH inikezela ngeemodeli ezintathu: i-extraarticular (01.1107), i-lateral (5100-17), kunye ne-medial (5100-18) iipleyiti.
VII. Ukuqukumbela
Unyango lotyando lulandela imigaqo ye-AO: ukunciphisa i-anatomical, ukulungiswa okuzinzile, kunye nokuvuselelwa kwangaphambili.
I-distal tibial fractures ixhaphakile, kwaye unyango lwendabuko lunemida
I-distal tibial fractures luhlobo oluqhelekileyo lokuphuka kwemilenze ephantsi. Unyango lwesintu olufana neepleyiti zokutshixa kunye nezikhonkwane ze-antegrade intramedullary nganye inemiqobo yazo. Iipleyiti zokutshixa zinokubangela izifo emva kokuhlinzwa okanye i-necrosis yezicubu ezithambileyo, ukwandisa ukubuyiswa; nangona izikhonkwane ze-antegrade zincinci, zingonakalisa idolo elihlangeneyo, zibangele intlungu, kwaye zithwale imingcipheko yokungalungiswa ngokwaneleyo okanye ukungahambi kakuhle, ukuthintela ukubuyiswa.
Iipleyiti zokutshixa:
Umonakalo obalulekileyo wezicubu ezithambileyo, izinga eliphezulu losulelo, ukubuyisela ixesha elide
Izikhonkwane ze-Antegrade:
Umngcipheko wokulimala kwamadolo, ukulungiswa okunganelanga, ukulungelelaniswa nokungahambi kakuhle
Isisombululo esitsha: I-Distal Tibial Nail (DTN)
Inketho yonyango entsha-i-Distal Tibial Nail (i-DTN)-inika imbono entsha yokulawula i-distal tibial fractures kunye noyilo olukhethekileyo lokubuyisela.
Uyilo lofakelo lokubuyisela umva lubonelela ngendlela entsha
Ukubekwa kwesigulane kunye nokulungiswa kokunciphisa
Isigulane sibekwe kwindawo yokulala. Iifractures ezifudusiweyo kufuneka zincitshiswe ngesandla; ukuba kuyimfuneko, sebenzisa iiforcep zokunciphisa ukuncedisa phambi kokufaka i-DTN. Ukuba kukho i-fibular fracture ehamba kunye, ukulungelelaniswa okufanelekileyo kwe-fibular kunokuncedisa ukunciphisa i-tibial. I-Fibular shaft fractures inokuzinziswa ngezikhonkwane ze-intramedullary. Ukuphuka kwe-ankle, ukunciphisa i-anatomical kunye nokulungiswa kwe-fibula kufuneka kulandele ukunciphisa i-tibial ukuphepha ukungahambi kakuhle. Kwiifractures ezivulekileyo kunye nokulungiswa kwangaphandle okukhoyo, isikhonkwane sinokufakwa ngelixa sigcina i-fixator ukuphumeza ukunciphisa.
Ukuma kwe-Supine, sebenzisa i-forceps yokunciphisa ukuba kuyimfuneko
Ukubeka phambili ulawulo lwe-fibular fracture ukuqinisekisa ukunciphisa okuchanekileyo kwe-tibial
I-2-3 cm ye-longitudinal incision yenziwa kwincam ye-malleolus ephakathi ukuveza i-deltoid ligament engaphezulu. Ikhoni yesikhokelo ifakwe okanye iphakathi kancinci kwinqanaba le-malleolus (Umfanekiso 2a), 4-5 mm ukusuka kwi-articular surface. Umbono osecaleni ubonisa ukufakwa nge-intercondylar groove (Umfanekiso 2b), ukuphepha umonakalo kwi-posterior tibialis muscle. Yahlula i-superficial deltoid ligament, emva koko usebenzise i-reamer ukwandisa i-medullary canal ukuya kwindawo ye-metaphyseal (Umfanekiso we-2c). Susa ithambo elikhansela kufuphi ne-proximal medial cortex ukufaka isikhonkwane (Umfanekiso we-2d). Faka isikhonkwane sokulinga ukuqinisekisa ubungakanani be-DTN (Umfanekiso 2e). Kuphephe ukubetha ngehamile okanye ukujija ngokugqithisileyo ukuthintela ukwaphuka kwe-iatrogenic medial malleolar. Lungisa ubunzulu bezikhonkwane ukuqinisekisa ukuba izikrufu ezikude azingeni kwindawo edibeneyo ye-ankle okanye indawo yokuphuka. Ukulungiswa kufezekiswa ngee-screws ezidibeneyo ngokusondeleyo kunye ne-distally.
Ukusika:
I-longitudinal cut in the medial malleolus tip
Indawo yesikhonkwane sesikhokelo:
4-5 mm ukusuka kwindawo edibeneyo
Ukucinga kunye nesikhonkwane sovavanyo:
Ream ukuya kwi-metaphysis, qinisekisa ubungakanani bezikhonkwane
Ufakelo lwezikhonkwane:
Gwema ukubethelwa, lungisa ubunzulu ukukhusela ukujoyina
Ukulungiswa:
Izikrufu ezidibeneyo ngokusondeleyo kunye ne-distally
Inkqubo yokufaka i-DTN
Ukuhamba ngokudibeneyo kwe-ankle kunye nokuqhagamshelana nonyawo ukuya phantsi kuvunyelwe emva kokuhlinzwa
Ukungathwali ubunzima kwiiveki ze-4-6
Ukuqhubela phambili kwisisindo esipheleleyo phakathi kweeveki ze-8-12, ngelixa ubeka iliso kwi-callus kunye nentlungu.Umsebenzi odibeneyo we-Ankle uqala ngokukhawuleza emva kokuhlinzwa
Kuphephe ukuthwala ubunzima kwiiveki ezi-4-6
Ukutshintshela ngokuthe ngcembe kwisisindo esipheleleyo kwiiveki ezi-8-12
Ukulandelelwa kwezigulane ezili-10
Uphononongo lulandele izigulane ze-10 (Itheyibhile 1). Ngeenyanga ezi-3 emva kokuphuma, iimeko ezisi-7 sele ziphilisiwe; zonke izigulane zifumene ukuphiliswa kwiinyanga ezi-6. Imeko enye yevarus kunye ne-recurvatum deformities yenzeka. Akukho kulahleka kokunciphisa, ukusuleleka, iingxaki ezinxulumene nokufakelwa, okanye ukulimala kwe-iatrogenic kwabonwa (Itheyibhile 2).
Iimeko ezi-7 ziphiliswa kwiinyanga ezi-3; bonke baphiliswe ngeenyanga ezi-6
2 ukukhubazeka kancinci (1 varus, 1 recurvatum)
Akukho usulelo, iingxaki zokufakelwa, okanye ukuncipha kwelahleko
Umguli oneminyaka engama-69 ubudala
Uhlobo lokwaphuka:
Ukwahlukana kwe-tibial fracture + i-fibular fracture
Ingxaki:
Ukulimala kwezicubu ezithambileyo
Emva kokuvula:
Kuphela ama-6 amancinci amancinci, ukuphilisa okupheleleyo ngaphakathi kwe-1 unyaka
Amanani 3 & 4:
Imifanekiso yeRadiographic kunye ne-postoperative recovery
Iimpawu ze-DTN
Olu pho nonongo lubandakanya i-AO 43-A kunye ne-C1 fractures; I-C2 nayo yaqwalaselwa. I-DTNs zifumaneka ngobude be-7 mm kunye ne-8 mm, ezimisela ukubekwa kwe-screws proximal interlocking. Iifractures ezibekwe kwi-2-9 cm ngaphezu kwendawo ye-articular ngabaviwa abafanelekileyo bokulungiswa kwe-DTN. Iimpawu zinokuthi zandiswe kwi-AO 42 fractures.
Isebenza kwi-AO 43-A, C1, cinga ukwandisa ukuya kwi-C2 kunye ne-42
Iziphumo ezingcono kakhulu zokuqhekeka kwe-2-9 cm ukusuka kwindawo edibeneyo
Ukuzinza kweBiomechanical
Izikhonkwane ze-retrograde zine-axial ephezulu kunye nokuqina okujikelezayo xa kuthelekiswa namacwecwe okutshixa aphakathi kunye nezikhonkwane ze-antegrade. Greenfield et al. kwenziwe uvavanyo lwe-biomechanical olubonisa ukuba ukusebenzisa izikrufu ezibini ze-distal kwi-DTN kuzuze i-60-70% yokuqina koxinzelelo kunye ne-90% yokuqina kwe-torsional xa kuthelekiswa nezikrufu ezithathu. I-DTN yehlise intshukumo yeqhekeza leqhekeza phantsi komthwalo. Kwiimeko ezi-3 ezingazange ziphole kwiinyanga ze-3, izinto ziquka umonakalo wezicubu ezithambileyo, ukwanda kwe-medullary, indawo yokuphuka, kunye ne-osteoporosis. Kuba ii-DTNs ziza ngeesayizi ezintathu kuphela kwaye ukulungiswa kwe-distal kukhawulelwe kwizikrufu ezithathu, zinokubonelela ngokungonelanga kozinzo kwimijelo ebanzi okanye ithambo le-osteoporotic. Ukuthwala ubunzima kwangoko kufuneka kuthethwe ngononophelo kwiimeko ezinjalo.
Uphakamileyo kwiipleyiti zokutshixa kunye nezikhonkwane ze-antegrade
Isicwangciso sokulungiswa esicetyiswayo: 2 proximal + 3 distal screws
Izinto ezilungileyo ze-DTN
Xa kuthelekiswa neepleyiti zokutshixa, izikhonkwane ze-intramedullary zenza umonakalo omncinci wezicubu ezithambileyo, ngakumbi ezifanelekileyo kwizigulane ezisele zikhulile kunye nezo zonzakele kakhulu kwizicubu ezithambileyo ezivela kumonzakalo wamandla aphezulu. Kolu phononongo, ii-DTNs zafakwa nge-incision emithandathu kuphela, ngaphandle kweengxaki zezicubu ezithambileyo. Inkqubo ayifuni ukuguqa ngamadolo, ukunciphisa umngcipheko wokunciphisa ilahleko kunye nokwenza ukuba ifaneleke izigulane ezinedolo elilinganiselweyo (umzekelo, i-knee arthritis okanye i-post-TKA).
Ubuncinci obuhlaselayo, bulungele abantu abadala kunye nezigulana zomonzakalo wamandla aphezulu
Akukho kuguqulwa kwamadolo okufunekayo, okufanelekileyo ukuhamba kwamadolo okulinganiselwe
Imingcipheko yoTyando kunye nokuQaphela
Iingozi ziquka ukulimala kwi-posterior tibialis muscle kunye ne-medial malleolar fracture. Ukuqhekeka kwe-malleolar ephakathi kunokunyangwa nge-band band wiring, i-plating, okanye ukulungiswa kwangaphandle.
Kufuneka kuthatyathwe unonophelo ukuze kuthintelwe ukungena ngezikrufu kwinotshi yefibula. Isixhobo sokumisa sinokubangela ukujikeleza ngasemva kwe-DTN ngenxa yobunzima bayo; lungisa isikrufu sesibini ukuba sibhekiselele kwifibula (Fig. 4c).Iingxaki ezinokuthi zibekho:
Ukulimala kwe-posterior tibialis, i-medial malleolar fracture
Ulawulo:
Ibhendi yoxinzelelo, iplating, okanye isilungisi sangaphandle
Icala lesixhobo kunye nobungakanani besixhobo sokumisa bufuna ingqwalasela yangaphakathi
Uthelekiso lweklinikhi
Amazinga angabonakaliyo kunye nokungahambi kakuhle kwezikhonkwane ze-antegrade yi-0-25% kunye ne-8.3-50%, ngokulandelanayo; kwiipleyiti zokutshixa, i-0-17% kunye ne-0-17%. Kulo cwaningo, zonke iimeko ezifunyenwe umanyano, kwaye kuphela i-20% yayinokukhubazeka> i-5 °, xa kuthelekiswa neendlela zendabuko. usulelo olunzulu luyi-0-23% kunye ne-0-8.3%, ngokulandelanayo. Olu phononongo luchaze ukuba akukho zingxaki zezicubu ezithambileyo, zisebenza ukodlula zombini iindlela ezizezinye.Amanqaku asebenzayo:
Amanqaku e-AOFAS kwizikhonkwane ze-antegrade: 86-88 (uhlobo A), 73 (uhlobo C); amacwecwe okutshixa: 84–88 (uhlobo A)
Olu phononongo: Umyinge we-AOFAS: 92.6
I-EQ-5D-5L: Amacwecwe okuvala: 0.62-0.76; olu phononongo: 0.876
I-SAFE-Q (izigulane zeenyawo kunye ne-ankle): 67-75; esi sifundo: 83–91.7 (Itheyibhile 3)
Izinga loManyano, izinga lokukhubazeka, kunye nezinga losulelo ligqwesile kwiindlela zakwaNtu
Amanqaku asebenzayo (AOFAS, EQ-5D-5L, SAFE-Q) abonisa iziphumo ezigqwesileyo
Isishwankathelo, i-DTN inikezela ngeenzuzo ngaphezu kweeplate zokutshixa kunye ne-antegrade intramedullary izikhonkwane kwaye imele isisombululo esisebenzayo sokunyanga i-distal tibial fractures.
I-DTN ibonakalisa ukungahlaseli okuncinci, ukuzinza okuphezulu, kunye nokuchacha ngokukhawuleza
Yeyona ndlela ixabisekileyo kunyango lwesintu kwaye ifanele ukukhuthazwa
