ʻIke ʻia ka malunion navicular ma kahi o 5-15% o nā haki ʻoi āpau o ka iwi navicular, me ka necrosis navicular e kū nei ma kahi o 3%. ʻO nā mea pilikia no ka malunion navicular e komo pū me ka ʻike ʻole ʻia a lohi paha, ka kokoke kokoke o ka laina haki, ka neʻe ʻana ma mua o 1 mm, a me ka haki me ka carpal instability. Inā ʻaʻole mālama ʻia, pili pinepine ka navicular osteochondral nonunion me ka traumatic arthritis, i ʻike ʻia hoʻi ʻo navicular osteochondral nonunion me ka collapsing osteoarthritis.
Hiki ke hoʻohana ʻia ke kāpili iwi me ka ʻole o kahi flap vascularised e mālama i ka navicular osteochondral nonunion. Eia nō naʻe, no nā poʻe maʻi me ka osteonecrosis o ka pou proximal o ka iwi navicular, ʻaʻole maikaʻi nā hopena o ke kāpili iwi me ka ʻole o kahi piko vascular, a ʻo ka helu ho'ōla iwi he 40%-67% wale nō. I ka hoʻohālikelike ʻana, hiki i ka helu ho'ōla o nā kāpili iwi me nā flaps vascularised ke kiʻekiʻe e like me 88%-91%. ʻO nā flaps iwi vascularised nui i ka hana lapaʻau e komo pū ana me ka 1,2-ICSRA-tipped distal radius flap, bone graft + vascular bundle implant, palmar radius flap, free iliac bone flap me ka vascularised tip, a me ka medial femoral condylar bone flap (MFC VBG), etc. He maikaʻi nā hopena o ke kāpili iwi me ka vascularised tip. Ua hōʻike ʻia ka free MFC VBG he pono i ka mālama ʻana i nā haki navicular me ka metacarpal collapse, a hoʻohana ka MFC VBG i ka lālā articular o ke aʻa kuli iho ma ke ʻano he lālā trophic nui. Ke hoʻohālikelike ʻia me nā flaps ʻē aʻe, hāʻawi ka MFC VBG i ke kākoʻo kūkulu kūpono e hoʻihoʻi i ke ʻano maʻamau o ka iwi navicular, ʻoi aku hoʻi i ka navicular fracture osteochondrosis me ke kūlou ʻana o ke kua (Kiʻi 1). I ka mālama ʻana i ka navicular osteochondral osteonecrosis me ka holomua o ka carpal collapse, ua hōʻike ʻia ka 1,2-ICSRA-tipped distal radius flap he 40% wale nō ka nui o ka ho'ōla ʻana o ka iwi, ʻoiai ʻo ka MFC VBG he 100% ka nui o ka ho'ōla ʻana o ka iwi.
Kiʻi 1. Ka haki o ka iwi navicular me kahi deformity "bowed back", hōʻike ʻo CT i ka poloka haki ma waena o nā iwi navicular ma kahi kihi o 90°.
Hoʻomākaukau ma mua o ke ʻoki ʻana
Ma hope o ka hoʻokolokolo kino ʻana o ka pulima i hoʻopilikia ʻia, pono e hana ʻia nā haʻawina kiʻi e loiloi i ke kiʻekiʻe o ka hiolo ʻana o ka pulima. He mea pono nā radiographs maʻamau e hōʻoia i kahi o ka haki, ke kiʻekiʻe o ka neʻe ʻana, a me ke alo o ka resorption a i ʻole sclerosis o ka ʻaoʻao haʻihaʻi. Hoʻohana ʻia nā kiʻi posterior anterior e loiloi no ka hiolo ʻana o ka pulima, ka paʻa ʻole o ka pulima (DISI) me ka hoʻohana ʻana i ka lakio kiʻekiʻe o ka pulima i hoʻololi ʻia (kiʻekiʻe/laulā) o ≤1.52 a i ʻole kahi kihi radial lunate ʻoi aku ma mua o 15°. Hiki i ka MRI a i ʻole CT ke kōkua i ka ʻike ʻana i ka malalignment o ka iwi navicular a i ʻole osteonecrosis. ʻO nā radiographs lateral a i ʻole oblique sagittal CT o ka iwi navicular me kahi kihi navicular >45° e hōʻike ana i ka pōkole o ka iwi navicular, i ʻike ʻia ʻo "bowed back deformity". MRI T1, T2 hōʻailona haʻahaʻa e hōʻike ana i ka necrosis o ka iwi navicular, akā ʻaʻohe manaʻo koʻikoʻi o ka MRI i ka hoʻoholo ʻana i ka ho'ōla ʻana o ka haki.
Nā hōʻailona a me nā contraindications:
ʻO ka nonunion osteochondral Navicular me ke kūlou ʻana o ke kua a me DISI; Hōʻike ka MRI i ka necrosis ischemic o ka iwi navicular, ka wehe ʻana o ka tourniquet intraoperative a me ka nānā ʻana i ka haki i haki ʻia ka hopena o ka iwi navicular he iwi sclerotic keʻokeʻo nō; ʻo ka hāʻule ʻana o ka hoʻopili iwi wedge mua a i ʻole ka hoʻopaʻa ʻana o ka wili i loko e pono ai kahi hoʻopili iwi VGB nui (>1cm3). nā ʻike mua a intraoperative paha o ka osteoarthritis o ka hui carpal radial; inā ua loaʻa ka malunion navicular koʻikoʻi me ka osteoarthritis collapsing, a laila pono paha ka denervation wrist, navicular osteotomy, quadrangular fusion, proximal carpal osteotomy, total carpal fusion, etc.; navicular malunion, proximal necrosis, akā me ke ʻano maʻamau o ka iwi navicular (e laʻa, ka haki navicular non-displaced me ka lako koko maikaʻi ʻole i ka pou 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 pani no kahi flap radius distal).
Anatomy i hoʻopili ʻia
Hoʻolako ʻia ka MFC VBG e kekahi mau kīʻaha trophoblastic liʻiliʻi interosseous (awelika 30, 20-50), me ka nui o ke koko e waiho ana ma hope o ka condyle femoral medial (awelika 6.4), ukali ʻia e ka anterior superior (awelika 4.9) (Kiʻi 2). ʻO kēia mau kīʻaha trophoblastic i hoʻolako nui ʻia e ke aʻa geniculate descending (DGA) a/a i ʻole ke aʻa geniculate medial superior (SMGA), ʻo ia ka lālā o ke aʻa femoral superficial e hāʻawi pū ana i nā lālā aʻalolo articular, musculocutaneous, a/a i ʻole saphenous. ua hoʻomaka ka DGA mai ke aʻa femoral superficial proximal i ka medial eminence o ka medial malleolus, a i ʻole ma kahi mamao o 13.7 cm proximal i ka ʻili articular (10.5-17.5 cm), a ʻo ke kūpaʻa o ka lālā he 89% i nā specimens cadaveric (Kiʻi 3). Hoʻomaka ka DGA mai ke aʻa femoral superficial ma 13.7 cm (10.5 cm-17.5 cm) proximal i ka medial malleolus fissure a i ʻole proximal i ka ʻili articular, me kahi hāpana 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 kūpono o ka mea mua no ka tibiae ma muli o ka lōʻihi a me ke anawaena o ke kīʻaha koko.
Kiʻi 2. Ka hoʻolaha ʻana o ʻehā-quadrant o nā kīʻaha MFC trophoblast ma ka laina ʻaoʻao ma waena o ka semitendinosus a me ka medial collateral ligament A, ka laina o ka trochanter nui B, ka laina o ke pou kiʻekiʻe o ka patella C, ka laina o ka meniscus mua D.
Kiʻi 3. Anatomy vascular MFC: (A) Nā lālā extraosseous a me ke anatomy vascular trophoblastic MFC, (B) Ka mamao o nā kumu vascular mai ka laina hui
Ke komo ʻana i ke ʻoki kino
Hoʻonoho ʻia ka mea maʻi ma lalo o ka anesthesia laulā ma ke kūlana moe, me ka lālā i hoʻopilikia ʻia e kau ʻia ma ka papa ʻoki lima. Ma ke ʻano laulā, lawe ʻia ka ʻili iwi hāʻawi mai ka ipsilateral medial femoral condyle, i hiki i ka mea maʻi ke neʻe me nā crutches ma hope o ke ʻoki ʻana. Hiki ke koho ʻia ke kuli contralateral inā he mōʻaukala o ka trauma ma mua a i ʻole ke ʻoki ʻana ma ka ʻaoʻao like o ke kuli. Kūlou ke kuli a hoʻohuli ʻia ka ʻūhā i waho, a hoʻopili ʻia nā tourniquets i nā ʻaoʻao o luna a me lalo. ʻO ke ʻano ʻoki ʻana, ʻo ia ke ʻano Russe i hoʻonui ʻia, me ka ʻoki ʻana e hoʻomaka ana he 8 cm proximal i ka transverse carpal tunnel a e hoʻolōʻihi ana mai ka ʻaoʻao radial o ka radial flexor carpi radialis tendon, a laila pelu ma ka transverse carpal tunnel i ke kumu o ka manamana nui, e pau ana ma ka pae o ka trochanter nui. Ua ʻoki ʻia ka ʻūpā tendon o ke tendon radial longissimus a ua huki ʻia ke tendon ulnarly, a ua hōʻike ʻia ka iwi navicular ma o ka ʻoki ʻoi ʻana ma ke kaula radial lunate a me ke kaula radial navicular head, me ka hoʻokaʻawale pono ʻana o nā ʻiʻo palupalu peripheral o ka iwi navicular e ʻae i ka hōʻike hou ʻana o ka iwi navicular (Kiʻi 4). E hōʻoia i ka ʻāpana o ka nonunion, ke ʻano o ke cartilage articular a me ke kiʻekiʻe o ka ischaemia o ka iwi navicular. Ma hope o ka wehe ʻana i ka tourniquet, e nānā i ka pou proximal o ka iwi navicular no ke kahe koko punctate e hoʻoholo ai inā he ischaemic necrosis. Inā ʻaʻole pili ka navicular necrosis me ka radial carpal a i ʻole intercarpal arthritis, hiki ke hoʻohana ʻia ʻo MFC VGB.
Kiʻi 4. Ke ʻano hana ʻoki navicular: (A) Hoʻomaka ka ʻoki ʻana ma kahi kokoke i ka tunnel carpal transverse a hoʻolōʻihi i ka lihi radial o ke aʻalolo radial flexor carpi radialis i ka ʻāpana distal o ka ʻoki ʻana, kahi i pelu ʻia i ke kumu o ka manamana nui ma ka tunnel carpal transverse. (B) Ua ʻoki ʻia ka ʻūpā tendon o ke aʻalolo radial longissimus a ua huki ʻia ke aʻalolo ulnarly, a ua hōʻike ʻia ka iwi navicular ma ka ʻoki ʻoi ma ke kaula radial lunate a me ke kaula radial navicular head. (C) E ʻike i kahi o ka discontinuity osseous navicular.
Hana ʻia kahi ʻoki ʻana he 15-20 cm ka lōʻihi ma kahi kokoke i ka laina hui kuli ma ka palena hope o ka ʻiʻo femoral medial, a hoʻihoʻi ʻia ka ʻiʻo i mua e hōʻike i ka lako koko MFC (Kiʻi 5). Hoʻolako pinepine ʻia ka lako koko MFC e nā lālā articular o ka DGA a me ka SMGA, e lawe pinepine ana i ka lālā hui nui o ka DGA a me ke aʻa e pili pū ana. Hoʻokuʻu ʻia ka pedicle vascular ma kahi kokoke, e mālama pono ana i ka periosteum a me nā kīʻaha trophoblastic ma ka ʻili iwi.
Kiʻi 5. Ke komo ʻana i ka MFC: (A) Hana ʻia kahi ʻoki he 15-20 cm ka lōʻihi ma kahi kokoke ma ka palena hope o ka ʻiʻo femoral medial mai ka laina hui kuli. (B) Hoʻihoʻi ʻia ka ʻiʻo i mua e hōʻike i ka lako koko MFC.
Ka hoʻomākaukau ʻana o ka iwi navicular
Pono e hoʻoponopono ʻia ka navicular DISI deformity a hoʻomākaukau ʻia ka ʻāpana o ka osteochondral bone graft ma mua o ke kau ʻana ma ke kulou ʻana i ka pulima ma lalo o ka fluoroscopy e hoʻihoʻi i kahi radial lunate angle maʻamau (Kiʻi 6). Ua wili ʻia kahi pine Kirschner 0.0625 kapuaʻi (ma kahi o 1.5-mm) ma ke ʻano percutaneous mai ka dorsal a i ka metacarpal e hoʻopaʻa i ka radial lunate joint, a ua hōʻike ʻia ka navicular malunion gap ke hoʻopololei ʻia ka pulima. Ua hoʻomaʻemaʻe ʻia ka hakahaka haki mai nā ʻiʻo palupalu a ua hoʻopaʻa hou ʻia me kahi plate spreader. Hoʻohana ʻia kahi ʻoki reciprocating liʻiliʻi e hoʻopalahalaha i ka iwi a hōʻoia i ka like ʻana o ka implant flap me kahi ʻano rectangular ma mua o kahi wedge, e koi ana e lawelawe ʻia ka navicular gap me kahi ākea ākea ma ka ʻaoʻao palmar ma mua o ka ʻaoʻao dorsal. Ma hope o ka wehe ʻana i ka hakahaka, ua ana ʻia ke kīnā ma nā ana ʻekolu e hoʻoholo ai i ka nui o ka iwi graft, ʻo ia hoʻi he 10-12 mm ka lōʻihi ma nā ʻaoʻao a pau o ka graft.
Kiʻi 6. Hoʻoponopono ʻana i ke ʻano kūlou o ke kua o ka navicular, me ka fluoroscopic flexion o ka pulima lima e hoʻihoʻi i ke kūlike radial-lunar maʻamau. Ua wili ʻia kahi pine Kirschner 0.0625 kapuaʻi (ma kahi o 1.5-mm) ma ke ʻano percutaneous mai ka dorsal a i ka metacarpal e hoʻopaʻa i ka hui radial lunate, e hōʻike ana i ka hakahaka malunion navicular a hoʻihoʻi i ke kiʻekiʻe maʻamau o ka iwi navicular ke hoʻopololei ʻia ka pulima lima, me ka nui o ka hakahaka e wānana ana i ka nui o ka flap e pono e ʻoki ʻia.
ʻOsteotomy
Ua koho ʻia ka ʻāpana vascularised o ka medial femoral condyle ma ke ʻano he wahi o ka unuhi ʻana o ka iwi, a ua hōʻailona kūpono ʻia ka ʻāpana o ka unuhi ʻana o ka iwi. E makaʻala ʻaʻole e hōʻeha i ka ligament collateral medial. Ua ʻoki ʻia ka periosteum, a ua ʻoki ʻia kahi ʻāpana iwi reciprocating o ka nui kūpono no ka ʻāpana i makemake ʻia me kahi ʻoki reciprocating, me ka lua o ka poloka iwi i ʻoki ʻia ma 45° ma kekahi ʻaoʻao e hōʻoia i ka pono o ka ʻāpana (Kiʻi 7). 7). Pono e mālama pono ʻaʻole e hoʻokaʻawale i ka periosteum, ka iwi cortical, a me ka iwi cancellous o ka ʻāpana. Pono e hoʻokuʻu ʻia ka tourniquet o ka ʻaoʻao haʻahaʻa e nānā i ke kahe ʻana o ke koko ma o ka ʻāpana, a pono e hoʻokuʻu ʻia ka pedicle vascular ma kahi kokoke no ka liʻiliʻi he 6 cm e ʻae ai i ka anastomosis vascular ma hope. Inā pono, hiki ke hoʻomau ʻia kahi liʻiliʻi o ka iwi cancellous i loko o ka femoral condyle. Ua hoʻopiha ʻia ka hemahema condylar femoral me kahi pani hoʻopili iwi, a ua hoʻokahe ʻia ka ʻoki a pani ʻia papa ma ka papa.
Kiʻi 7. Ka wehe ʻana i ka ʻili iwi MFC. (A) Ua māka ʻia ka ʻāpana osteotomy e lawa ai e hoʻopiha i ka hakahaka navicular, ua ʻoki ʻia ka periosteum, a ua ʻoki ʻia kahi ʻili iwi huinahā o ka nui kūpono no ka ʻili i makemake ʻia me kahi ʻoki reciprocating. (B) Ua ʻoki ʻia kahi ʻāpana iwi ʻelua ma kekahi ʻaoʻao ma 45° e hōʻoia i ka pono o ka ʻili.
Hoʻokomo ʻana a me ka hoʻopaʻa ʻana o ka flap
Ua ʻoki ʻia ka ʻili iwi i ke ʻano kūpono, me ka mālama pono ʻaʻole e ʻomi i ka pedicle vascular a i ʻole e wehe i ka periosteum. Hoʻokomo mālie ʻia ka ʻili i loko o ka ʻāpana o ka hemahema o ka iwi navicular, e pale ana i ka percussion, a hoʻopaʻa ʻia me nā wili navicular hakahaka. Ua mālama pono ʻia e hōʻoia i ka palena palmar o ka poloka iwi i hoʻokomo ʻia e like me ka palena palmar o ka iwi navicular a i ʻole ua emi iki ia e pale aku i ka hoʻopili ʻana. Ua hana ʻia ka Fluoroscopy e hōʻoia i ke ʻano o ka iwi navicular, ka laina o ka ikaika a me ke kūlana wili. Anastomose i ke aʻa flap vascular i ka hopena o ke aʻa radial i ka ʻaoʻao a me ka piko venous i ka vein hoa radial artery mai ka hopena a i ka hopena (Kiʻi 8). Hoʻoponopono ʻia ka capsule hui, akā ua pale ʻia ka pedicle vascular.
Kiʻi 8. Ke kau ʻana o ka ʻili iwi, ka hoʻopaʻa ʻana, a me ka anastomosis vascular. Hoʻokomo mālie ʻia ka ʻili iwi i loko o ka ʻāpana o ke kīnā iwi navicular a hoʻopaʻa ʻia me nā wili navicular hakahaka a i ʻole nā pine Kirschner. E mālama pono ʻia e pili pono ka palena metacarpal o ka poloka iwi i hoʻokomo ʻia me ka palena metacarpal o ka iwi navicular a i ʻole e hoʻohaʻahaʻa iki ʻia e pale aku i ka hoʻopili ʻana. Ua hana ʻia ka anastomosis o ke aʻa flap vascular i ke aʻa radial mai ka hopena a ka hopena, a ua hana ʻia ka piko o ke aʻa i ke aʻa hoa radial a ka hopena a ka hopena.
Hoʻoponopono hou ʻana ma hope o ke ʻoki ʻana
ʻO ka aspirin waha 325 mg i kēlā me kēia lā (no 1 mahina), ʻae ʻia ka hāpai kaumaha ma hope o ke kaʻina hana o ka lālā i hoʻopilikia ʻia, hiki i ka hoʻopaʻa ʻana i ke kuli ke hōʻemi i ka ʻoluʻolu ʻole o ka mea maʻi, ma muli o ka hiki o ka mea maʻi ke neʻe i ka manawa kūpono. Hiki i ke kākoʻo contralateral o kahi crutches hoʻokahi ke hōʻemi i ka ʻeha, akā ʻaʻole pono ke kākoʻo lōʻihi o nā crutches. Ua wehe ʻia nā humuhumu 2 mau pule ma hope o ke ʻoki ʻana a ua mālama ʻia ka Muenster a i ʻole ka lima lōʻihi i ka manamana lima no 3 mau pule. Ma hope o kēlā, hoʻohana ʻia ka lima pōkole i ka manamana lima a hiki i ka wā e hoʻōla ai ka haki. Lawe ʻia nā kukuna X ma nā manawa 3-6 pule, a ua hōʻoia ʻia ka hoʻōla ʻana o ka haki e CT. Ma hope iho, pono e hoʻomaka mālie nā hana flexion a me ka extension hana a me ka passive, a pono e hoʻonui mālie ʻia ka ikaika a me ka pinepine o ka hoʻoikaika kino.
Nā pilikia nui
ʻO nā pilikia nui o ka hui kuli, ʻo ia ka ʻeha kuli a i ʻole ka ʻeha o ke aʻalolo. Ua ʻike nui ʻia ka ʻeha kuli i loko o 6 mau pule ma hope o ke ʻoki ʻana, a ʻaʻohe nalowale sensory a i ʻole neuroma ʻeha ma muli o ka ʻeha o ke aʻalolo saphenous i loaʻa. ʻO nā pilikia nui o ka pulima, ʻo ia ka nonunion iwi refractory, ka ʻeha, ka ʻoʻoleʻa o ke aʻalolo, ka nāwaliwali, ka osteoarthritis holomua o ka pulima radial a i ʻole nā iwi intercarpal, a ua hōʻike pū ʻia ka pilikia o ka ossification heterotopic periosteal.
Hoʻopili ʻana i ka iwi Vascularised Medial Femoral Condyle manuahi no nā Scaphoid Nonunions me ka Proximal Pole Avascular Necrosis a me Carpal Collapse
Ka manawa hoʻouna: Mei-28-2024
