Ko te huarahi suprapatellar he huarahi pokanga whakarerekētia mō te whao tibial intramedullary i te tūranga turi haurua-toro. He maha ngā painga, engari he maha ngā ngoikoretanga, o te mahi i te whao intramedullary o te tibia mā te huarahi suprapatellar i te tūranga hallux valgus. Kua taunga ētahi taote pokanga ki te whakamahi i te SPN hei rongoā i ngā whati tibial katoa engari ko ngā whati extra-articular o te proximal 1/3 o te tibia.
Ko ngā tohu mō te SPN ko:
1. Ngā whati whati kua tapahia, kua wāhanga rānei o te kakau tibial. 2;
2. ngā whati o te metaphysis tibial distal;
3. te whati o te hope, o te turi rānei me te whakawhāititanga o te piko o mua (hei tauira, te hononga hope kua pirau, te hononga honohono rānei, te osteoarthritis o te turi) te kore rānei e taea te piko o te turi, te hope rānei (hei tauira, te nekenga o muri o te hope, te whati o te femur ipsilateral);
4. te whati o te tibial me te whara kiri i te uaua infrapatellar;
5. he whati o te tibia i roto i tētahi tūroro he roa rawa te tibia (he uaua te kite i te pito tata o te tibia i raro i te tirotiro ā-pūoro ina nui ake te roa o te tibia i te roa o te tūru e taea ai e te tirotiro ā-pūoro te haere).
Ko te painga o te tikanga whao tibial intramedullary tibia position semi-extended turi mō te rongoā i te mid-tibial diaphysis me ngā whati tibial distal kei roto i te māmā o te neke me te ngāwari o te fluoroscopy. Mā tēnei huarahi ka taea te tautoko pai i te roanga katoa o te tibia me te whakaiti ngāwari i te whati sagittal me te kore e hiahiatia te whakarerekē (Pikitia 1, 2). Mā tēnei ka kore e hiahiatia he kaiawhina whakangungu hei āwhina i te tikanga whao intramedullary.
Pikitia 1: Te tūranga noa mō te tikanga whao intramedullary mō te huarahi infrapatellar: kei te tū te turi i runga i te tūru ka taea te uru ki te fluoroscopic. Heoi, ka taea e tēnei tūranga te whakararu i te tūnga ngoikore o te poraka whati, ā, me whai tikanga whakaiti anō mō te whakaiti i te whati.
Pikitia 2: He rerekē, ko te tūnga turi roa i runga i te arawhata pahuka ka āwhina i te whakatikatika poraka whati me te whakahaere i muri mai.
Ngā Tikanga Pokanga
Tēpu / Tūnga Kei te takoto takoto te tūroro i runga i te moenga fluoroscopic. Ka taea te mahi i te toia o te pito o raro, engari kāore e hiahiatia. He pai te tēpu vascular mō te whao tibial intramedullary approach suprapatellar, engari kāore e hiahiatia. Heoi, ko te nuinga o ngā moenga whakatakoto whati, ngā moenga fluoroscopic rānei kāore i te tūtohutia nā te mea kāore e tika mō te whao tibial intramedullary approach suprapatellar.
Mā te whakakī i te huha ipsilateral ka āwhina i te pupuri i te pito o raro ki te tūranga hurihuri ki waho. Kātahi ka whakamahia he arawhata pahuka parakore hei whakaara ake i te peka e pāngia ana ki runga ake i te taha contralateral mō te fluoroscopy posterolateral, ā, mā te tūranga hope me te turi piko ka āwhina hoki ki te ārahi i te whakatakotoranga o te titi me te whao intramedullary. Kei te tautohetia tonutia te koki piko turi tino pai, me Beltran et al. e kī ana he piko turi 10°, me Kubiak e kī ana he piko turi 30°. E whakaae ana te nuinga o ngā tohunga he pai ngā koki piko turi i roto i ēnei awhe.
Heoi, i kitea e Eastman me ētahi atu, i te piki haere o te koki piko o te turi mai i te 10° ki te 50°, ka heke te pānga o te maikuku femur ki te werohanga kiri o te taputapu. Nō reira, mā te koki piko nui ake o te turi ka āwhina i te whiriwhiri i te tūranga whakauru whao intramedullary tika me te whakatika i ngā koki koki i te papa sagittal.
Te tirotiro i te pūoro
Me whakanoho te mīhini ringa-C ki te taha kē atu o te tēpu mai i te peka e pāngia ana, ā, ki te tū te taote pokanga ki te taha o te turi e pāngia ana, me noho te aroturuki ki te pane o te mīhini ringa-C, me te tata tonu. Mā tēnei ka taea e te taote pokanga me te tohunga hihi-X te tirotiro ngāwari i te aroturuki, engari mēnā ka whakauruhia he whao honohono tawhiti. Ahakoa kāore i te whakahauhia, e taunaki ana ngā kaituhi kia nekehia te ringa-C ki te taha kotahi, me te taote pokanga ki te taha kē atu ina panaia he tīwiri honohono waenga. Waihoki, me whakanoho te mīhini ringa-C ki te taha e pāngia ana i te wā e mahi ana te taote pokanga i te tukanga ki te taha contralateral (Pikitia 3). Koinei te tikanga e whakamahia whānuitia ana e ngā kaituhi nā te mea ka karohia te hiahia o te taote pokanga ki te neke mai i te taha waenga ki te taha taha i te wā e panaia ana te whao raka tawhiti.
Pikitia 3: Kei te taha kē atu o te tibia e pāngia ana te taote pokanga kia ngāwari ai te pana i te tīwiri raka waenga. Kei te ritenga atu o te taote pokanga te whakaaturanga, i te pane o te ringa-C.
Ka tangohia ngā tirohanga fluoroscopic anteroposterior me medial-lateral katoa me te kore e nekehia te peka e pāngia ana. Mā tēnei ka karohia te nekehanga o te wāhi whati kua tautuhia anō i mua i te whakatikatikanga katoa o te whati. Hei tāpiri, ka taea te tiki whakaahua o te roa katoa o te tibia me te kore e whakatītaha i te ringa-C mā te tikanga kua whakaahuahia i runga ake nei.
Tapahi kiri He pai ngā tapahi iti me ngā tapahi torotika. Ko te huarahi suprapatellar percutaneous mō te whao intramedullary e hangai ana ki te whakamahinga o te tapahi 3-cm hei pana i te whao. Ko te nuinga o ēnei tapahi pokanga he roa, engari ka taea hoki te whakawhiti, e ai ki te taunakitanga a Tākuta Morandi, ā, ko te tapahi torotika i whakamahia e Tākuta Tornetta me ētahi atu e tohuhia ana mō ngā tūroro he subluxation patellar whakakotahi, he huarahi parapatellar medial, lateral rānei te nuinga. E whakaatu ana te Pikitia 4 i ngā tapahi rerekē.
Pikitia 4: Whakaahua o ngā momo tikanga tapahi pokanga.1- Te huarahi tapahi hononga transpatellar suprapatellar; 2- Te huarahi tapahi hononga parapatellar; 3- Te huarahi tapahi hononga parapatellar medial limited incision; 4- Te huarahi tapahi hononga parapatellar medial prolonged incision; 5- Te huarahi tapahi hononga parapatellar lateral. Ka taea te whakaatu hohonu o te huarahi tapahi hononga parapatellar mā roto i te hononga, i waho rānei o te bursa hononga.
Te whakaaturanga hōhonu
Ko te huarahi suprapatellar percutaneous ka mahia mā te wehe roa i te uaua quadriceps kia taea rā anō te whakauru i te āputa ki te haere o ngā taputapu pēnei i ngā whao intramedullary. Ko te huarahi ligament parapatellar, e haere ana i te taha o te uaua quadriceps, ka tohua pea mō te tikanga whao intramedullary tibial. Ka tukuna marietia he ngira trocar punga me te cannula mā roto i te hononga patellofemoral, he tikanga e ārahi ana i te pūwāhi urunga o mua-runga o te whao intramedullary tibial mā te trocar femoral. Kia tika te whakanoho o te trocar, me whakau ki tōna tūranga kia kore ai e pakaru te kiriuhi hononga o te turi.
Ka taea te whakamahi i tētahi tikanga tapahi nui whakawhiti-pūmau me te tapahi kiri parapatellar hyperextension, me te huarahi taha, taha rānei. Ahakoa kāore ētahi taote pokanga e tiaki i te bursa i te wā o te pokanga, e whakapono ana a Kubiak me ētahi atu me tiaki tonu te bursa, ā, me whakaatu pai ngā hanganga i waho o te hononga. I roto i te ariā, he pai te tiaki i te hononga turi, ā, ka ārai i ngā kino pēnei i te mate turi.
Kei roto hoki i te huarahi kua whakaahuatia i runga ake nei te hemi-dislocation o te patella, e whakaiti ana i te pēhanga pa ki ngā mata hononga ki tētahi taumata. Mēnā he uaua ki te mahi aromatawai hononga patellofemoral me te kōhao hononga iti me te taputapu toronga turi iti rawa, ka tūtohu ngā kaituhi kia taea te wehe i te patella mā te wehenga hononga. I tētahi atu taha, mā te tapahi whakawhiti waenga ka karo i te kino o ngā hononga tautoko, engari he uaua ki te mahi i tētahi whakatikatika whara turi angitu.
He rite tonu te pūwāhi whakauru ngira SPN ki te pūwāhi whakauru infrapatellar. Mā te fluoroscopy o mua me te taha i te wā e whakaurua ana te ngira ka whakarite kia tika te pūwāhi whakauru ngira. Me whakarite e te taote pokanga kia kaua e werohia te ngira ārahi ki muri rawa ki roto i te tibia proximal. Mena ka werohia ki muri rawa, me nekehia te tūranga mā te āwhina o te whao ārai i raro i te fluoroscopy coronal o muri. Hei tāpiri, e whakapono ana a Eastman me ētahi atu mā te keri i te pine whakauru i roto i te tūranga turi piko nui ka āwhina i te nekehia o te whati i muri mai i te tūranga hyperextended.
Ngā taputapu whakaiti
Ko ngā taputapu whai hua mō te whakaiti ko ngā pūwero whakaiti ira o ngā rahi rerekē, ngā pūwero hiki i te huha, ngā taputapu whakapiri o waho, me ngā pūwero whakatika o roto mō te whakapiri i ngā kongakonga whati iti me te pereti cortical kotahi. Ka taea hoki te whakamahi i ngā whao ārai mō te tukanga whakaiti kua whakahuatia ake nei. Ka whakamahia ngā hama whakaiti hei whakatika i ngā kopa piko me ngā kopa nekehanga whakawhiti.
Ngā whakatō
He maha ngā kaihanga o ngā taputapu whakatikatika ā-roto orthopedic kua whakawhanake i ngā pūnaha whakamahi taputapu hei ārahi i te whakatakotoranga paerewa o ngā whao tibial intramedullary. Kei roto ko te ringa whakatakotoranga kua toroa, he taputapu ine roa o te pine ārahi, me te taputapu whakawhānui medullary. He mea tino nui kia tiakina pai te urunga mai o ngā pine trocar me ngā pine trocar pūngoi ki roto i te whao intramedullary. Me whakaū anō te taote pokanga i te tūranga o te cannula kia kore ai e whara te hononga patellofemoral, ngā hanganga periarticular rānei nā te tata rawa ki te taputapu taraiwa.
Ngā tīwiri maukati
Me whakarite e te taote pokanga kia nui te maha o ngā tīwiri raka e whakaurua ana kia mau tonu te whakaiti pai. Ko te whakapiri i ngā kongakonga whati iti (proximal, distal rānei) ka oti mā te whakamahi i te 3, neke atu rānei o ngā tīwiri raka i waenganui i ngā kongakonga whati tata, mā te whakamahi rānei i ngā tīwiri koki-pūmau anake. Ko te huarahi suprapatellar ki te tikanga whao tibial intramedullary he rite ki te huarahi infrapatellar e pā ana ki te tikanga taraiwa tīwiri. He tika ake te taraiwa i ngā tīwiri raka i raro i te fluoroscopy.
Te katinga o te patunga
Mā te momi i tētahi anga o waho e tika ana i te wā e whakawhanuitia ana ka tangohia ngā kongakonga wheua kore utu. Me whakamakuku pai ngā patunga katoa, inā koa te wāhi i pokaina ai te turi. Kātahi ka katihia te uaua quadriceps, te paparanga ligament rānei me te tuitui i te wāhi i pakaru ai, ā, muri iho ka katihia te kiri me te kiri.
Te tango i te whao intramedullary
Kei te tautohetia tonutia mēnā ka taea te tango i te whao tibial intramedullary i werohia mā te huarahi suprapatellar mā te huarahi pokanga rerekē. Ko te huarahi tino noa ko te huarahi transarticular suprapatellar mō te tango i te whao intramedullary. Ka whakaatuhia te whao e tēnei tikanga mā te keri mā te awaawa whao intramedullary suprapatellar mā te whakamahi i te wiri tuwhera 5.5 mm. Kātahi ka werohia te taputapu tango whao mā te awaawa, engari he uaua pea tēnei mahi. Ko ngā huarahi parapatellar me infrapatellar he tikanga rerekē mō te tango i ngā whao intramedullary.
Ngā Mōrearea Ko ngā mōrearea pokanga o te huarahi suprapatellar ki te tikanga whao tibial intramedullary ko te whara hauora ki te kiriuhi patella me te femoral talus, te whara hauora ki ētahi atu hanganga hononga-roto, te mate hononga, me ngā paru-roto hononga-roto. Heoi, kāore he pūrongo take haumanu e rite ana. Ka nui ake te tūponotanga o ngā tūroro e pāngia ana e te chondromalacia ki ngā whara kiriuhi i puta mai i te rongoā. Ko te kino hauora ki ngā hanganga mata hononga patellar me te femoral he āwangawanga nui mō ngā taote pokanga e whakamahi ana i tēnei huarahi pokanga, inā koa te huarahi transarticular.
I tēnei wā, kāore anō kia kitea he taunakitanga haumanu e pā ana ki ngā painga me ngā ngoikoretanga o te tikanga whao tibial intramedullary semi-extension.
Wā tuku: Oketopa-23-2023
