Malunion Navicular na-eme ihe dị ka 5-15% nke ọkpụkpụ navicular niile gbawara agbawa, yana necrosis navicular na-eme ihe dị ka 3%. Ihe ndị nwere ike ibute malunion navicular gụnyere nchọpụta a na-atụghị anya ya ma ọ bụ igbu oge, nso nke ahịrị mgbawa ahụ, mgbanwe karịrị 1 mm, na mgbawa ahụ na-enweghị ike ịkwụsi ike na carpal. Ọ bụrụ na a hapụghị ya, a na-ejikọkarị ya na osteochondral nonion navicular na traumatic arthritis, nke a makwaara dị ka navicular osteochondral nonion na-agbawa agbawa na osteoarthritis.
Enwere ike iji ịkpụ ọkpụkpụ navicular ma ọ bụ na-enweghị flap vascularized gwọọ navicular osteochondral nonion. Agbanyeghị, maka ndị ọrịa nwere osteonecrosis nke ogidi proximal nke ọkpụkpụ navicular, nsonaazụ nke ịkpụ ọkpụkpụ na-enweghị nsọtụ vascular adịghị mma, ọnụego ọgwụgwọ ọkpụkpụ dịkwa naanị 40%-67%. N'aka nke ọzọ, ọnụego ọgwụgwọ nke ịkpụ ọkpụkpụ na-enweghị flap vascularized nwere ike ịdị elu ruo 88%-91%. Isi flap ọkpụkpụ vascularized na ọgwụgwọ gụnyere flap radius distal 1,2-ICSRA-tipped, bone graft + vascular bundle implant, palmar radius flap, free iliac bone flap with vascularized tip, na medial femoral condylar bone flap (MFC VBG), wdg. Nsonaazụ nke ịkpụ ọkpụkpụ na tip vascularized dị mma. Egosipụtala na MFC VBG efu dị irè n'ịgwọ mgbawa navicular na metacarpal daa, MFC VBG na-ejikwa alaka articular nke akwara ikpere na-agbada dị ka alaka trophic bụ isi. Ma e jiri ya tụnyere ihe ndị ọzọ e ji akpụ akpụ, MFC VBG na-enye nkwado zuru oke iji weghachi ọdịdị nkịtị nke ọkpụkpụ navicular, ọkachasị na ọkpụkpụ navicular nke nwere nkwarụ azụ gbagọrọ agbagọ (Foto 1). N'ọgwụgwọ nke ọkpụkpụ navicular nke osteochondral nke nwere nkwarụ carpal na-aga n'ihu, akọpụtala na flap radius distal nke nwere isi 1,2-ICSRA nwere naanị 40% ọgwụgwọ ọkpụkpụ, ebe MFC VBG nwere ọnụego ọgwụgwọ ọkpụkpụ nke 100%.
Foto nke 1. Mgbaji ọkpụkpụ navicular nwere mgbanwe "gbagọrọ agbagọ", CT na-egosi ngọngọ mgbawa dị n'etiti ọkpụkpụ navicular n'akụkụ ihe dị ka 90°.
Nkwadebe tupu ịwa ahụ
Mgbe enyochachara aka ahụ nke aka ahụ metụtara, a ga-eme nnyocha onyonyo iji chọpụta oke mgbawa aka. Nyocha redio nkịtị bara uru iji kwado ebe mgbawa ahụ dị, oke mgbanwe, na ọnụnọ nke resorption ma ọ bụ sclerosis nke njedebe gbajiri agbaji. A na-eji onyonyo ihu azụ iji chọpụta ọdịda aka, enweghị ntụkwasị obi nke aka (DISI) site na iji oke ogologo aka agbanwere agbanwe (ịdị elu/obosara) nke ≤1.52 ma ọ bụ akụkụ radial lunate nke karịrị 15°. MRI ma ọ bụ CT nwere ike inye aka chọpụta adịghị mma nke ọkpụkpụ navicular ma ọ bụ osteonecrosis. Nyocha redio dị n'akụkụ ma ọ bụ CT sagittal oblique nke ọkpụkpụ navicular nwere akụkụ navicular >45° na-egosi mkpụmkpụ nke ọkpụkpụ navicular, nke a maara dị ka "nkwarụ azụ gbajiri agbaji". MRI T1, T2 ala mgbaàmà na-egosi necrosis nke ọkpụkpụ navicular, mana MRI enweghị ihe doro anya dị mkpa n'ịchọpụta ọgwụgwọ nke mgbawa ahụ.
Ihe ngosi na contraindications:
Ọ bụrụ na ọkpụkpụ navicular adịghị n'otu ebe, ọ nwere nkwarụ azụ gbagọrọ agbagọ na DISI; MRI na-egosi ischemic necrosis nke ọkpụkpụ navicular, ịtọpụ tourniquet n'ime ịwa ahụ na ịhụ mgbawa nke akụkụ ọkpụkpụ navicular gbajiri agbaji ka bụ ọkpụkpụ sclerotic ọcha; ọdịda nke mbụ nke ịkpụkọta ọkpụkpụ wedge ma ọ bụ nhazi ime skru chọrọ nnukwu nhazi ọkpụkpụ VGB (＞1cm3). Nchọpụta tupu ịwa ahụ ma ọ bụ n'ime ịwa ahụ nke osteoarthritis nke nkwonkwo carpal radial; ọ bụrụ na nnukwu malunion navicular na-ada ada emeela, mgbe ahụ enwere ike ịchọ nkwojiaka, osteotomy navicular, njikọ quadrangular, osteotomy carpal proximal, njikọ carpal zuru oke, wdg.; malunion navicular, necrosis proximal, mana yana ọdịdị ọkpụkpụ navicular nkịtị (dịka ọmụmaatụ, mgbawa navicular na-enweghị mgbanwe na ọbara na-adịghị na poolu proximal); mkpụmkpụ nke malunion navicular na-enweghị osteonecrosis. (Enwere ike iji 1,2-ICSRA dị ka nnọchi maka flap radius distal).
Ọdịdị Ejiri Mee Ihe
A na-enye MFC VBG site na ọtụtụ obere arịa trophoblastic interosseous (nkezi 30, 20-50), ebe ọbara kachasị ukwuu dị ala karịa medial femoral condyle (nkezi 6.4), nke na-esote anteriorly superior (nkezi 4.9) (Foto 2). A na-enye arịa trophoblastic ndị a site na akwara geniculate na/ma ọ bụ akwara geniculate dị elu (SMGA), nke bụ alaka nke akwara femoral dị elu nke na-emekwa ka alaka akwara articular, musculocutaneous, na/ma ọ bụ saphenous pụta. DGA sitere na akwara femoral dị elu nke dị nso na etiti medial malleolus, ma ọ bụ n'ebe dị anya nke 13.7 cm nso na elu articular (10.5-17.5 cm), nkwụsi ike nke alaka ahụ bụ 89% na ihe atụ cadaveric (Foto 3). DGA sitere na akwara femoral dị elu nke dị sentimita 13.7 (10.5 cm-17.5 cm) nso na etiti malleolus fissure ma ọ bụ nso na elu akwara, yana ihe nlele cadaveric na-egosi nkwụsi ike 100% nke alaka na dayameta nke ihe dị ka 0.78 mm. Ya mere, a na-anabata DGA ma ọ bụ SMGA, ọ bụ ezie na nke mbụ dabara adaba maka tibiae n'ihi ogologo na dayameta nke arịa ahụ.
Foto nke 2. Nkesa akụkụ anọ nke arịa MFC trophoblast n'akụkụ ahịrị kwụ ọtọ n'etiti semitendinosus na njikọ etiti A, ahịrị nke trochanter B ka ukwuu, ahịrị nke ogwe elu nke patella C, ahịrị nke meniscus ihu D.
Foto nke 3. MFC vascular anatomy: (A) Alaka ndị pụrụ iche na MFC trophoblastic vascular anatomy, (B) Anya nke mmalite vascular site na njikọ ahụ
Ụzọ ịwa ahụ
A na-etinye onye ọrịa ahụ n'okpuru ọgwụ mgbu n'akụkụ isi ya, a na-etinyekwa akụkụ ahụ metụtara n'elu tebụl ịwa ahụ aka. N'ozuzu, a na-ewepụ ọkpụkpụ onye nyere onyinye site na condyle nke etiti femoral, ka onye ọrịa wee nwee ike ịgagharị na ihe mgbochi mgbe a wachara ya ahụ. Enwere ike ịhọrọ ikpere nke dị n'akụkụ ma ọ bụrụ na enwere akụkọ ihe mere eme nke mmerụ ahụ ma ọ bụ ịwa ahụ gara aga n'otu akụkụ ikpere. A na-agbatị ikpere ahụ ma na-atụgharị úkwù n'èzí, a na-etinyekwa tourniquets na nsọtụ elu na ala. Ụzọ ịwa ahụ bụ ụzọ Russe gbatịpụrụ agbatị, ebe mbepụ ahụ malitere 8 cm nso na ọwara carpal transverse ma gbasaa site na nsọtụ radial nke radial flexor carpi radial tendon, wee na-apịachi na ọwara carpal transverse gaa na ntọala mkpịsị aka ukwu, na-akwụsị na ọkwa nke trochanter ka ukwuu. A na-apịa ihe mkpuchi akwara nke radial longissimus tendon ma dọpụta akwara ahụ n'ọkpụkpụ azụ, a na-ekpughekwa ọkpụkpụ navicular site na nkewa dị nkọ n'akụkụ akwara radial lunate na radial navicular isi, yana nkewa nke anụ ahụ dị nro nke akụkụ ahụ navicular iji mee ka ọkpụkpụ navicular pụta ìhè ọzọ (Foto nke 4). Chọpụta ebe a na-anaghị ejikọta ọnụ, ịdị mma nke cartilage articular na ogo ischaemia nke ọkpụkpụ navicular. Mgbe ị tọpụsịrị tourniquet ahụ, lelee ogidi proximal nke ọkpụkpụ navicular maka ọbara ọgbụgba punctate iji chọpụta ma enwere ischaemic necrosis. Ọ bụrụ na navicular necrosis ejikọtaghị ya na radial carpal ma ọ bụ intercarpal arthritis, enwere ike iji MFC VGB.
Foto nke 4. Ụzọ ịwa ahụ Navicular: (A) Mbepụ ahụ na-amalite site na 8 cm nso na ọwara carpal transverse ma gbasaa nsọtụ radial nke radial flexor carpi radialis tendon ruo n'akụkụ dị anya nke mbepụ ahụ, nke a na-apịachi gaa na ntọala mkpịsị aka ukwu na ọwara carpal transverse. (B) A na-apịa ihe mkpuchi akwara nke radial longissimus tendon ma dọpụta akwara ahụ n'ụzọ ulnar, a na-ekpughekwa ọkpụkpụ navicular site na mwepụ dị nkọ n'akụkụ radial lunate na radial navicular head ligaments. (C) Chọpụta mpaghara nke navicular osseous discontinuity.
A na-eme mbepụ dị sentimita iri na ise ruo iri abụọ (15-20 cm) n'akụkụ eriri nkwonkwo ikpere n'akụkụ ókèala azụ nke akwara femoral medial, a na-atụgharịkwa akwara ahụ n'ihu iji kpughee ọbara MFC (Foto nke 5). Ọ bụ alaka akwara nke DGA na SMGA ka a na-enye ọbara MFC, na-ejikarị alaka nkwonkwo buru ibu nke DGA na akwara ndị kwekọrọ na ya. A na-ahapụ pedicle akwara ahụ nso, na-akpachara anya ichebe periosteum na arịa trophoblastic dị n'elu ọkpụkpụ.
Foto nke 5. Ịwa ahụ iji banye na MFC: (A) A na-eme mbepụ dị sentimita 15-20 n'ogologo n'akụkụ ókèala azụ nke akwara femoral medial site na njikọ ikpere. (B) A na-atụgharị akwara ahụ n'ihu iji kpughee ọbara MFC.
Nkwadebe nke ọkpụkpụ navicular
A ghaghị idozi nsogbu ọkpụkpụ navicular DISI ma kwadebe mpaghara ọkpụkpụ osteochondral tupu e tinye ya site n'ịgbanwe aka n'okpuru fluoroscopy iji weghachi akụkụ radial lunate nkịtị (Foto nke 6). A na-egwupụta pin Kirschner nke dị mita 0.0625 (ihe dị ka 1.5-mm) site na dorsal ruo metacarpal iji dozie njikọ lunate radial, a na-ekpughekwa oghere malunion navicular mgbe a gbatịchara aka. E wepụrụ oghere mgbawa ahụ site na anụ ahụ dị nro ma meghee ya na ihe na-agbasa efere. A na-eji obere mmanu na-agbanwe agbanwe eme ka ọkpụkpụ ahụ dị larịị ma hụ na flap implant yiri ihe owuwu akụkụ anọ karịa wedge, nke chọrọ ka ejiri oghere navicular jikwaa oghere ahụ na palmar karịa n'akụkụ azụ. Mgbe emepechara oghere ahụ, a na-atụ ntụpọ ahụ n'akụkụ atọ iji chọpụta oke nke graft ọkpụkpụ, nke na-abụkarị 10-12 mm n'ogologo n'akụkụ niile nke graft ahụ.
Foto nke 6. Ndozi nke mgbanwe azụ gbagọrọ agbagọ nke navicular, site na iji fluoroscopic na-emegharị aka iji weghachi nhazi radial-lunar nkịtị. A na-egwupụta pin Kirschner nke dị 0.0625-foot (ihe dị ka 1.5-mm) site na azụ ruo na metacarpal iji dozie njikọ radial lunate, na-ekpughe oghere malunion navicular ma weghachite ịdị elu nkịtị nke ọkpụkpụ navicular mgbe a gbadoro aka, yana nha oghere ahụ na-ebu amụma nha nke flap nke a ga-achọ ka a gbochie.
Ọkpụkpụ ọkpụkpụ
A na-ahọrọ mpaghara vascular nke medial femoral condyle dị ka ebe a na-ewepụta ọkpụkpụ, a na-ahụkwa mpaghara mwepụ ọkpụkpụ nke ọma. Kpachara anya ka ị ghara imerụ akwara etiti ahụ ahụ. A na-egbutu periosteum ahụ, a na-egbutukwa ọkpụkpụ akụkụ anọ nke nha kwesịrị ekwesị maka flap achọrọ site na iji ihe e ji akwọ ihe, a na-egbutukwa ọkpụkpụ nke abụọ na 45° n'otu akụkụ iji hụ na flap ahụ kwụsiri ike (Foto 7). 7). A ga-akpachara anya ka a ghara ikewapụ periosteum, ọkpụkpụ cortical, na ọkpụkpụ cancellous nke flap ahụ. A ga-ahapụ tourniquet nke dị n'akụkụ ala iji hụ ka ọbara si na flap ahụ na-agafe, a ga-ahapụkwa pedicle nke akwara ahụ nso nso ruo opekata mpe 6 cm iji mee ka anastomosis nke akwara na-esote pụta. Ọ bụrụ na ọ dị mkpa, enwere ike ịga n'ihu na obere ọkpụkpụ cancellous n'ime femoral condyle. A na-ejupụta ntụpọ femoral condylar na ihe nnọchite anya ọkpụkpụ, a na-awụpụkwa mbepụ ahụ ma mechie oyi akwa site na oyi akwa.
Foto nke 7. Mwepụ ọkpụkpụ MFC. (A) A na-akara mpaghara osteotomy zuru oke iji jupụta oghere navicular, a na-egbutu periosteum, a na-eji ihe e ji akwọ ihe na-agbanwe agbanwe gbubie ọkpụkpụ akụkụ anọ nke nha kwesịrị ekwesị maka mkpuchi achọrọ. (B) A na-egbutu ọkpụkpụ nke abụọ n'otu akụkụ na 45° iji hụ na mkpuchi ahụ kwụsiri ike.
Ịtinye na itinye flap
A na-akpụzi ihe mkpuchi ọkpụkpụ ahụ ka ọ dị n'ụdị kwesịrị ekwesị, na-akpachara anya ka a ghara ịpịkọta ihe mkpuchi akwara ma ọ bụ wepụ periosteum ahụ. A na-etinye ihe mkpuchi ahụ nwayọ n'ebe ọkpụkpụ navicular ahụ nwere ntụpọ, na-ezere ịkụ ọkpọ, ma jiri skru navicular oghere dozie ya. A kpachara anya iji hụ na akụkụ palmar nke ihe mkpuchi ọkpụkpụ a kụnyere na-acha ọbara ọbara na akụkụ palmar nke ọkpụkpụ navicular ma ọ bụ na e tinyere ya ntakịrị iji zere nsogbu. E mere fluoroscopy iji kwado ọdịdị ọkpụkpụ navicular, ahịrị ike na ọnọdụ skru. Anastomose akwara flap vascular ruo na nsọtụ akwara radial ruo n'akụkụ na nsọtụ akwara radial ruo na nsọtụ akwara radial (Foto 8). A na-arụzi kapsụl nkwonkwo ahụ, mana a na-ezere pedicle vascular.
Foto nke 8. Ịtinye ọkpụkpụ, idozi ya, na ọrịa akwara. A na-etinye ọkpụkpụ ahụ nwayọ n'ime mpaghara nke ntụpọ ọkpụkpụ navicular ma jiri skru navicular oghere ma ọ bụ pin Kirschner dozie ya. A na-akpachara anya ka akụkụ metacarpal nke ngọngọ ọkpụkpụ a kụnyere na-achagharị na akụkụ metacarpal nke ọkpụkpụ navicular ma ọ bụ na-akụda ya ntakịrị iji zere nsogbu. A na-eme anastomosis nke akwara flap vascular ruo na akwara radial site na nsọtụ ruo na nsọtụ, a na-emekwa nsọtụ akwara ruo na nsọtụ akwara radial.
Ndozigharị mgbe ịwa ahụ gasịrị
Aspirin a na-aṅụ 325 mg kwa ụbọchị (ruo otu ọnwa), a na-ekwe ka ibu ibu nke aka ahụ metụtara mee ihe mgbe a wachara ya ahụ, a na-eme ka ikpere ghara ịgbachi nkịtị nwere ike ibelata ahụ erughị ala nke onye ọrịa, dabere na ikike onye ọrịa nwere ịkwaga n'oge kwesịrị ekwesị. Nkwado nke otu ihe mgbochi nwere ike ibelata ihe mgbu, mana ọ dịghị mkpa ịkwado ihe mgbochi ogologo oge. E wepụrụ ihe mgbochi ahụ izu abụọ ka a wachara ya ahụ, a na-edebekwa Muenster ma ọ bụ ihe mgbochi aka ogologo ruo na mkpịsị aka ukwu ruo izu atọ. Mgbe nke ahụ gasịrị, a na-eji ihe mgbochi aka dị mkpụmkpụ ruo na mkpịsị aka ukwu ruo mgbe mgbawa ahụ ga-agwọ. A na-ewere X-ray na nkeji izu 3-6, a na-akwadokwa ọgwụgwọ mgbawa site na CT. Mgbe nke ahụ gasịrị, a ga-amalite mmegharị ahụ na mgbatị ahụ na mgbatị ahụ nwayọ nwayọ, a ga-amụbakwa ike na ugboro ole mmega ahụ.
Nsogbu ndị dị ukwuu
Nsogbu ndị bụ isi nke nkwonkwo ikpere gụnyere mgbu ikpere ma ọ bụ mmerụ ahụ akwara. Mgbu ikpere na-abụkarị n'ime izu isii ka a wachara ya ahụ, a hụghịkwa mfu mmetụta uche ma ọ bụ neuroma na-egbu mgbu n'ihi mmerụ ahụ akwara saphenous. Nsogbu ndị bụ isi nke nkwojiaka gụnyere enweghị njikọ ọkpụkpụ na-adịghị mma, ihe mgbu, ike nkwonkwo, adịghị ike, osteoarthritis na-aga n'ihu nke nkwojiaka radial ma ọ bụ ọkpụkpụ intercarpal, a kọwokwa ihe egwu nke heterotopic ossification periosteal.
Mkpịsị Ọkpụkpụ nke ejiri eriri afọ medium mee ihe n'efu maka Scaphoid Nonunions nwere necrosis avascular na ọdịda carpal
Oge ozi: Mee-28-2024
