Loaʻa ka malunion Navicular ma kahi o 5-15% o nā haʻihaʻi a pau o ka iwi navicular, me ka necrosis navicular e loaʻa ana ma kahi o 3%. ʻO nā kumu pilikia no ka malunion navicular, ʻo ia ka maʻi i hala a hoʻopaneʻe paha, kokoke kokoke i ka laina haʻihaʻi, ka neʻe ʻana i ʻoi aku ma mua o 1 mm, a me ka haki ʻana me ka paʻa ʻole o ka carpal. Inā haʻalele ʻole ʻia, pili pinepine ka navicular osteochondral nonunion me ka traumatic arthritis, i ʻike ʻia hoʻi ʻo ka navicular osteochondral nonunion me ka hāʻule ʻana o ka osteoarthritis.
Hiki ke hoʻohana ʻia ke kālai ʻana i ka iwi me ka ʻole o ka flap vascularised no ka mālama ʻana i ka navicular osteochondral nonunion. Eia nō naʻe, no nā poʻe maʻi me ka osteonecrosis o ka pole proximal o ka iwi hoʻokele, ʻaʻole i ʻoluʻolu nā hopena o ka hoʻopili ʻana i ka iwi me ka ʻole o ka vascular tip, a ʻo ka helu hoʻōla iwi he 40%-67% wale nō. I ka hoʻokaʻawale ʻana, hiki ke kiʻekiʻe ke kiʻekiʻe o ka hoʻōla ʻana o nā grafts iwi me nā flaps vascularised e like me 88% -91%. ʻO nā pā iwi vascularised nui i ka hana lapaʻau ʻo ia ka 1,2-ICSRA-tipped distal radius flap, iwi graft + vascular bundle implant, palmar radius flap, free iwi iliac flap with vascularised tip, and medial femoral condylar bone flap (MFC VBG), a pēlā aku. Ua ʻoluʻolu nā hopena o ke kālai ʻia ʻana o ka iwi me ka piko vascularised. Ua hōʻike ʻia ka maikaʻi o ka MFC VBG manuahi i ka mālama ʻana i nā haʻihaʻi navicular me ka hāʻule ʻana o ka metacarpal, a hoʻohana ka MFC VBG i ka lālā articular o ke aʻa kuli iho e like me ka lālā trophic nui. Ke hoʻohālikelike ʻia me nā flaps ʻē aʻe, hāʻawi ka MFC VBG i ke kākoʻo kūpono kūpono e hoʻihoʻi i ke ʻano maʻamau o ka iwi hoʻokele, ʻoi aku hoʻi i ka navicular fracture osteochondrosis me ke kūlou ʻana i hope (Figure 1). I ka mālama ʻana i ka osteochondral osteonecrosis navicular me ka holomua carpal collapse, ua hōʻike ʻia ka 1,2-ICSRA-tipped distal radius flap he 40% wale nō ka nui o ka ho'ōla iwi, ʻoiai ʻo ka MFC VBG he 100% hoʻōla iwi.
Kiʻi 1. ʻO ka haʻihaʻi o ka iwi hoʻokele me ka "kulou hope" deformity, hōʻike ʻo CT i ka poloka haʻi ma waena o nā iwi hoʻokele ma kahi kihi o 90°.
Hoʻomākaukau mua
Ma hope o ka nānā kino ʻana i ka lima i hoʻopilikia ʻia, pono e hana ʻia nā noiʻi kiʻi e nānā i ke ʻano o ka hāʻule ʻana o ka lima. Pono nā radiographs maʻamau e hōʻoia i kahi o ka haʻihaʻi, ke kiʻekiʻe o ka neʻe ʻana, a me ka loaʻa ʻana o ka resorption a i ʻole sclerosis o ka hopena haʻihaʻi. Hoʻohana ʻia nā kiʻi ma hope e loiloi no ka hāʻule ʻana o ka lima, ka ʻole o ke kua o ka lima (DISI) me ka hoʻohana ʻana i kahi ratio kiʻekiʻe o ka lima lima i hoʻololi ʻia (kiʻekiʻe/ākea) o ≤1.52 a i ʻole kahi kihi lunate radial ʻoi aku ma mua o 15°. Hiki i ka MRI a i ʻole CT ke kōkua i ka ʻike ʻana i ka maʻi ʻino o ka iwi navicular a i ʻole osteonecrosis. ʻO nā radiographs lateral a i ʻole oblique sagittal CT o ka iwi hoʻokele me kahi kihi hoʻokele > 45 ° e hōʻike ana i ka pōkole o ka iwi hoʻokele, i ʻike ʻia ʻo "kulou hope deformity". ʻaʻohe mea maopopo i ka hoʻoholo ʻana i ka hoʻōla ʻana o ka haʻihaʻi.
Nā hōʻailona a me nā contraindications:
Navicular osteochondral nonunion me ke kūlou hope deformity a me DSI; Hōʻike ʻo MRI i ka ischemic necrosis o ka iwi navicular, intraoperative loosening o ka tourniquet a me ka nānā ʻana i ka haʻi ʻana o ka hope o ka iwi navicular he iwi sclerotic keʻokeʻo; ʻo ka hemahema o ka grafting iwi wedge mua a i ʻole ka hoʻopaʻa ʻana i loko e pono ai ka grafting iwi nui VGB (>1cm3). nā ʻike mua a i ʻole intraoperative o ka osteoarthritis o ka hui carpal radial; inā ua nui ka malunion navicular me ka hāʻule ʻana o ka osteoarthritis, a laila pono ke koi ʻia ka denervation o ka lima, ka osteotomy navicular, quadrangular fusion, proximal carpal osteotomy, total carpal fusion, etc.; navicular malunion, proximal necrosis, akā me ka maʻamau o ka iwi navicular morphology (e laʻa, non-displaced navicular fracture me ka maikaʻi ʻole o ke koko i ka pole proximal); ka pōkole o ka malunion navicular me ka ʻole o ka osteonecrosis. (Hiki ke hoʻohana ʻia ka 1,2-ICSRA ma ke ʻano he mea pani no kahi flap radius distal).
Hoʻohana Anatomy
Hāʻawi ʻia ka MFC VBG e kekahi mau moku trophoblastic interosseous liʻiliʻi (mean 30, 20-50), me ka hāʻawi koko nui loa ma hope o ka condyle femoral medial (mean 6.4), a ukali ʻia e anteriorly superior (mean 4.9) ( Fig. 2). Hoʻolako nui ʻia kēia mau moku trophoblastic e ka geniculate artery iho (DGA) a me / a i ʻole ka superior medial geniculate artery (SMGA), ʻo ia ka lālā o ke aʻaʻa femoral superficial e hoʻoulu ai i nā lālā aʻalolo articular, musculocutaneous, a / a saphenous. . ʻO ka DGA i loaʻa mai ke aʻaʻa femoral superficial kokoke i ka medial eminence o ka medial malleolus, a i ʻole ma kahi mamao o 13.7 cm kokoke i ka ʻili articular (10.5-17.5 cm), a ʻo ke kūpaʻa o ka lālā he 89% i nā ʻano cadaveric. (Kiʻi 3). Hoʻomaka ka DGA mai ke aʻaʻa femoral superficial ma 13.7 cm (10.5 cm-17.5 cm) kokoke i ka malleolus fissure medial a i ʻole kokoke i ka ʻili articular, me kahi hōʻike cadaveric e hōʻike ana i ka 100% branching stability a me ke anawaena o kahi o 0.78 mm. No laila, ʻae ʻia ka DGA a i ʻole ka SMGA, ʻoiai ʻoi aku ka maikaʻi o ka mua no tibiae no ka lōʻihi a me ke anawaena o ka moku.
Fig. 2. Eha-quadrant mahele o ka MFC trophoblast moku ma ka laina paepae ma waena o ka semitendinosus a me ka medial collateral ligament A, laina o ka trochanter nui B, laina o ka pou luna o ka patella C, laina o ka mua meniscus D.
Kiʻi 3. MFC vascular anatomy: (A) Extraosseous lala a me MFC trophoblastic vascular anatomy, (B) Ka mamao o ka vascular origins mai ka laina hui.
ʻO ke komo ʻana i ke kino
Hoʻonoho ʻia ka mea maʻi ma lalo o ka anesthesia maʻamau ma ke kūlana supine, me ka lālā i hoʻopili ʻia ma luna o ka papa ʻaina lima. ʻO ka mea maʻamau, lawe ʻia ka pā iwi hāʻawi mai ka ipsilateral medial femoral condyle, i hiki i ka mea maʻi ke neʻe me nā koʻokoʻo ma hope o ke ʻoki ʻana. Hiki ke koho ʻia ke kuli contralateral inā loaʻa kahi moʻolelo o ka trauma ma mua a i ʻole ka ʻoki ʻana ma ka ʻaoʻao like o ka kuli. Hoʻopili ʻia ke kuli a hoʻohuli ʻia ka ʻūhā i waho, a hoʻohana ʻia nā tourniquets ma nā ʻaoʻao o luna a me lalo. ʻO ke ala ʻokiʻoki ʻo ia ke ala Russe lōʻihi, me ka ʻoki ʻana e hoʻomaka ana i ka 8 knm ma kahi kokoke i ka tunnel carpal transverse a hoʻolōʻihi ʻia mai ka ʻaoʻao radial o ka radial flexor carpi radialis tendon, a laila e pelu ʻia ma ke kaila carpal transverse i ke kumu o ka manamana lima. , e pau ana ma ka pae o ka trochanter nui. Ua ʻoki ʻia ka ʻāʻī o ka tendon radial longissimus a huki ʻia ka tendon i ka ulnarly, a ua ʻike ʻia ka iwi hoʻokele e ka ʻoki ʻoki ʻana ma ka radial lunate a me ka radial navicular head ligaments, me ka hoʻokaʻawale pono ʻana i nā ʻiʻo palupalu peripheral o ka iwi navicular e ʻae ai. ʻike hou aku i ka iwi hoʻokele (Figure 4). E hōʻoia i ka ʻāpana o ka nonunion, ka maikaʻi o ka cartilage articular a me ke degere o ka ischemia o ka iwi navicular. Ma hope o ka wehe ʻana i ka tourniquet, e nānā i ka pou proximal o ka iwi hoʻokele no ke kahe koko e hoʻoholo ai inā he ischemic necrosis. Inā ʻaʻole pili ka necrosis navicular me ka radial carpal a i ʻole intercarpal arthritis, hiki ke hoʻohana ʻia ka MFC VGB.
Kiʻi 4. ʻO ke kaʻina hana hoʻokele Navicular: (A) Hoʻomaka ka ʻoki ʻana i ka 8 knm ma kahi kokoke i ka tunnel carpal transverse a hoʻolōʻihi i ka ʻaoʻao radial o ka radial flexor carpi radialis tendon i ka ʻaoʻao mamao o ka ʻoki, i pelu ʻia i ke kumu o ka manamana lima. ma ke alahele carpal transverse. (B) Ua ʻoki ʻia ka ʻāʻī o ka radial longissimus tendon a huki ʻia ka ʻiʻo i ka ulnarly, a ʻike ʻia ka iwi hoʻokele e ka ʻoki ʻoki ʻana ma ka radial lunate a me ka radial navicular head ligaments. (C) E hoʻomaopopo i ka ʻāpana o ka pau ʻana o ka osseous navicular.
Hana ʻia kahi ʻoki lōʻihi 15-20 cm ma kahi kokoke i ka laina hui kuli ma ka palena hope o ka ʻiʻo femoral medial, a hoʻihoʻi ʻia ka ʻiʻo ma mua e hōʻike i ke koko MFC (Fig. 5). e nā lālā articular o ka DGA a me ka SMGA, e lawe maʻamau i ka lālā hui nui o ka DGA a me ka vein e pili ana. Hoʻokuʻu ʻia ka pedicle vascular ma kahi kokoke, e mālama pono i ka periosteum a me nā moku trophoblastic ma ka ʻili iwi.
Kiʻi 5. ʻO ke komo ʻana i ka MFC: (A) Hana ʻia kahi ʻokiʻoki 15-20 cm lōʻihi ma ka palena hope o ka ʻiʻo femoral medial mai ka laina hui kuli. (B) Hoʻihoʻi ʻia ka ʻiʻo ma mua e hōʻike i ke koko MFC..
Ka hoʻomākaukau ʻana i ka iwi hoʻokele
Pono e hoʻoponopono ʻia ka deformity DSI navicular a hoʻomākaukau ʻia ka ʻāpana o ka iwi osteochondral ma mua o ka hoʻokomo ʻana ma o ka hoʻoluli ʻana i ka lima ma lalo o ka fluoroscopy e hoʻihoʻi i kahi kihi radial lunate maʻamau (Figure 6). He 0.0625-kapuai (ma kahi o 1.5-mm) Kirschner pine i wili ʻia mai ke kua a hiki i ka metacarpal e hoʻopaʻa i ka hui radial lunate, a ʻike ʻia ka navicular malunion āpau ke hoʻopololei ʻia ka lima. Hoʻomaʻemaʻe ʻia ka wahi haʻi i ka ʻiʻo palupalu a hoʻopaʻa hou ʻia me kahi pā pālahalaha. Hoʻohana ʻia kahi wili pānaʻi liʻiliʻi e palahalaha i ka iwi a hōʻoia i ka like o ka implant flap i ʻoi aku ka like me ka ʻaoʻao o ka ʻaoʻao ʻaoʻao ma mua o ka wedge, kahi e pono ai e mālama ʻia ka navicular āpau me kahi ākea ākea ma ka ʻaoʻao palmar ma mua o ka ʻaoʻao hope. Ma hope o ka wehe ʻana i ke āpau, ua ana ʻia ka hemahema i ʻekolu mau ʻāpana e hoʻoholo ai i ka nui o ka graft iwi, ʻo ia ka 10-12 mm ka lōʻihi ma nā ʻaoʻao āpau o ke kāpili.
Kiʻi 6. Ka hoʻoponopono ʻana i ka deformity o ke kua i hope o ka navicular, me ka fluoroscopic flexion o ka pulima lima e hoʻihoʻi i ka alignment radial-lunar maʻamau. He 0.0625-kapuai (ma kahi o 1.5-mm) Kirschner pine i wili ʻia mai ka hope a hiki i ka metacarpal e hoʻopaʻa i ka hui radial lunate, e hōʻike ana i ka navicular malunion a me ka hoʻihoʻi ʻana i ke kiʻekiʻe maʻamau o ka iwi hoʻokele i ka wā e hoʻopololei ʻia ka pulima, me ka nui o ka āwaha e wānana ana i ka nui o ka pā e pono ke keakea.
Osteotomy
Ua koho ʻia ka ʻāpana vascularised o ka condyle femoral medial ma ke ʻano he wahi o ka unuhi ʻana o ka iwi, a ua hōʻailona pono ʻia ka wahi o ka ʻili iwi. E makaʻala i ʻole e hōʻeha i ka ligament collateral medial. Hoʻokiʻekiʻe ʻia ka periosteum, a ʻoki ʻia kahi ʻāpana iwi ʻehā o ka nui kūpono no ka peʻa i makemake ʻia me ka ʻili pānaʻi, me ka ʻoki ʻia ʻana o ka ʻāpana iwi ʻelua ma 45° ma kekahi ʻaoʻao e hōʻoia i ka pono o ka pā (Fig. 7). 7). Pono e mālama ʻole e hoʻokaʻawale i ka periosteum, iwi cortical, a me ka iwi cancellous o ka flap. Pono e hoʻokuʻu ʻia ka tourniquet ʻaoʻao haʻahaʻa e nānā i ke kahe ʻana o ke koko ma ka flap, a pono e hoʻokuʻu ʻia ka pedicle vascular proximally no ka liʻiliʻi o 6 knm e hiki ai i ka anastomosis vascular ma hope. Inā pono, hiki ke hoʻomau i ka iwi cancellous liʻiliʻi i loko o ka condyle femoral. Hoʻopiha ʻia ka defect condylar femoral me kahi pani iwi, a hoʻokahe ʻia ka ʻoki a pani ʻia i kēlā me kēia papa.
Kiʻi 7. ʻO ka wehe ʻana o ka iwi MFC. (A) Hōʻailona ʻia ka ʻāpana osteotomy e hoʻopiha ai i ka lewa hoʻokele, ʻoki ʻia ka periosteum, a ʻoki ʻia kahi ʻāpana iwi ʻehā o ka nui kūpono no ka pā i makemake ʻia me kahi ʻili reciprocating. (B) Ua ʻoki ʻia kekahi ʻāpana iwi ʻelua ma kekahi ʻaoʻao ma 45° e hōʻoia i ka pono o ka peʻa.
Hoʻopili ʻia a hoʻopaʻa ʻia
Hoʻokiʻoki ʻia ka pā iwi e like me ke ʻano kūpono, me ka mālama ʻole e hoʻopaʻa i ka pedicle vascular a i ʻole e wehe i ka periosteum. Hoʻokomo mālie ʻia ka flap i loko o ka wahi o ka hemahema o ka iwi hoʻokele, e pale ana i ka percussion, a hoʻopaʻa ʻia me nā wili hollow navicular screws. Ua mālama pono ʻia ka ʻili o ka pā lima o ka poloka iwi i hoʻokomo ʻia me ka ʻaoʻao palmar o ka iwi hoʻokele a i ʻole i hoʻohaʻahaʻa iki ʻia i mea e pale ai i ka paʻi ʻana. Ua hana ʻia ʻo Fluoroscopy e hōʻoia i ka morphology iwi navicular, laina o ka ikaika a me ke kūlana wili. Anastomose ke aʻaʻaʻaʻaʻaʻaʻaʻaʻaʻaʻaʻaʻaʻaʻaʻaʻa i ke aʻaʻaʻaʻaʻaʻaʻa radial hope a me ka venous welau i ke aʻaʻaʻaʻaʻaʻaʻaʻaʻa radial hope a me ka hopena (Figure 8). Hoʻoponopono ʻia ka capsule hui, akā pale ʻia ka pedicle vascular.
Kiʻi 8. Ka hoʻokomo ʻana o ka iwi iwi, ka hoʻopaʻa ʻana, a me ka anastomosis vascular. Hoʻokomo mālie ʻia ka pā iwi i loko o kahi o ka hemahema o ka iwi hoʻokele a hoʻopaʻa ʻia me nā wili hollow hollow a i ʻole nā pine Kirschner. E mālama pono ʻia ka ʻili ʻana o ka ʻaoʻao metacarpal o ka poloka iwi i hoʻokomo ʻia me ka ʻaoʻao metacarpal o ka iwi hoʻokele a i ʻole e hoʻohaʻahaʻa haʻahaʻa i mea e pale aku ai i ka paʻi ʻana. Hana ʻia ka Anastomosis o ke aʻaʻaʻaʻaʻaʻaʻa i ke aʻaʻa radial i ka hopena a i ka hopena, a ua hana ʻia ke aʻa aʻa i ke aʻa aʻa radial companion vein.
Hoʻoponopono ma hope o ka hana
ʻO ka aspirin waha 325 mg i kēlā me kēia lā (no ka mahina 1), ʻae ʻia ke kau ʻana i ke kaumaha o ka lālā i hoʻopilikia ʻia, hiki i ka braking kuli ke hōʻemi i ka ʻeha o ka mea maʻi, ma muli o ka hiki o ka mea maʻi ke neʻe i ka manawa kūpono. Hiki ke hoʻemi i ka ʻeha o ke koʻokoʻo hoʻokahi, akā ʻaʻole pono ke kākoʻo lōʻihi o nā koʻokoʻo. Wehe ʻia nā humuhumu he 2 pule ma hope o ka ʻoki ʻana a mālama ʻia ka Muenster a i ʻole ka lima lōʻihi i ka manamana lima no 3 pule. Ma hope o kēlā, hoʻohana ʻia ka lima pōkole i ka manamana lima a hiki i ka hoʻōla ʻana o ka haʻi. Lawe ʻia nā kukui X i nā manawa he 3-6 wiki, a ua hōʻoia ʻia ka hoʻōla ʻana o ka haʻihaʻi e CT. Ma hope iho, pono e hoʻomaka mālie ka hoʻoikaika a me ka passive flexion a me nā hana hoʻonui, a pono e hoʻonui mālie i ka ikaika a me ka pinepine o ka hoʻoikaika.
Nā pilikia nui
ʻO nā pilikia nui o ka hui kuli, ʻo ia ka ʻeha o ke kuli a i ʻole ka ʻeha nerve. Loaʻa ka ʻeha o ke kuli i loko o 6 mau pule ma hope o ka ʻoki ʻana, a ʻaʻole i ʻike ʻia ka nalo a i ʻole ka neuroma ʻeha ma muli o ka ʻeha nerve saphenous. ʻO nā pilikia nui o ka lima, ʻo ia ka iwi refractory nonunion, ʻeha, ʻoʻoleʻa hui, nāwaliwali, ka osteoarthritis holomua o ka radial wrist a i ʻole nā iwi intercarpal, a ua hōʻike pū ʻia ka pilikia o ka periosteal heterotopic ossification.
Free Medial Femoral Condyle Vascularised Bone Grafting no Scaphoid Nonunions me Proximal Pole Avascular Necrosis a me Carpal Collapse
Ka manawa hoʻouna: Mei-28-2024
