Ọkpụkpụ akwara na-apụta n'ihe dịka 5-15% nke nnukwu mgbaji ọkpụkpụ niile, yana necrosis navicular na-eme na ihe dịka 3%. Ihe ndị dị ize ndụ maka malunion navicular gụnyere nchoputa efu ma ọ bụ egbu oge, nso nso nke ahịrị mgbaji, nchụpụ karịa 1 mm, na mgbaji na-enwe nkụda mmụọ carpal. Ọ bụrụ na a naghị agwọta ya, a na-ejikọtakarị navicular osteochondral nounion na ọrịa ogbu na nkwonkwo, nke a makwaara dị ka navicular osteochondral nounion na osteoarthritis na-ada ada.
Enwere ike iji grafting ọkpụkpụ na-eji ma ọ bụ na-enweghị ọnyà vaskụla agwọ ọrịa navicular osteochondral nounion. Otú ọ dị, maka ndị ọrịa nwere osteonecrosis nke oghere dị nso nke ọkpụkpụ navicular, nsonaazụ nke ọkpụkpụ ọkpụkpụ na-enweghị ọnụ ọnụ vaskụla adịghị mma, na ọnụ ọgụgụ ọgwụgwọ ọkpụkpụ bụ nanị 40% -67%. N'ụzọ dị iche, ọnụ ọgụgụ ọgwụgwọ nke ọkpụkpụ ọkpụkpụ nwere flaps vaskụla nwere ike ịdị elu dị ka 88%-91%. Isi ọkpụkpụ ọkpụkpụ vaskụla na-eme n'ụlọ ọgwụ gụnyere 1,2-ICSRA-tipped distal radius flap, ọkpụkpụ graft + vascular bundle implant, palmar radius flap, free iliac flap free with vascularised n'ọnụ, na medial femoral condylar ọkpụkpụ flap (MFC VBG), wdg. Nsonaazụ nke ọkpụkpụ ọkpụkpụ na n'ọnụ vascularised na-eju afọ. MFC VBG n'efu ka egosiri na ọ dị irè n'ịgwọ mgbaji navicular na mgbawa metacarpal, na MFC VBG na-eji alaka articular nke akwara ikpere na-agbada dị ka alaka isi trophic. E jiri ya tụnyere flaps ndị ọzọ, MFC VBG na-enye nkwado nhazi zuru oke iji weghachi ọdịdị nkịtị nke ọkpụkpụ navicular, karịsịa na osteochondrosis navicular fracture osteochondrosis na nrụrụ agbada azụ (Njirimara 1). Na ọgwụgwọ nke osteochondral osteonecrosis navicular na carpal ọdịda na-aga n'ihu, 1,2-ICSRA-tipped distal radius flap ka akọọrọ na ọ nwere ọnụọgụ ọgwụgwọ ọkpụkpụ nke naanị 40%, ebe MFC VBG nwere ọnụ ọgụgụ ọgwụgwọ ọkpụkpụ nke 100%.
Ọgụgụ 1. Ọkpụkpụ nke ọkpụkpụ navicular nwere nrụrụ "ehulata azụ", CT na-egosi ngọngọ mgbaji n'etiti ọkpụkpụ azụ azụ na akụkụ nke ihe dịka 90 °.
Nkwadebe tupu ịwa ahụ
Mgbe nyochachara anụ ahụ nke nkwojiaka emetụtara, a ga-emerịrị ọmụmụ ihe onyonyo iji chọpụta ogo ọdịda nkwojiaka. Igwe redio dị larịị bara uru iji kwado ebe mgbawa ahụ, ogo nchụpụ, na ọnụnọ nke resorption ma ọ bụ sclerosis nke njedebe gbajiri agbaji. A na-eji ihe onyonyo dị n'azụ iji chọpụta maka ọdịda nkwojiaka, enweghị nkwụghachi azụ nke nkwojiaka (DISI) site na iji ogo ogo nkwojiaka gbanwere (ịdị elu / obosara) nke ≤1.52 ma ọ bụ akụkụ radial lunate nke karịrị 15º. MRI ma ọ bụ CT nwere ike inyere aka ịchọpụta mmebi nke ọkpụkpụ navicular ma ọ bụ osteonecrosis. Igwe redio dị n'akụkụ ma ọ bụ oblique sagittal CT nke ọkpụkpụ navicular nwere akụkụ navicular> 45 ° na-atụ aro mbelata ọkpụkpụ navicular, nke a maara dị ka "nrụrụ gbadatara azụ".MRI T1, T2 obere mgbaàmà na-egosi necrosis nke ọkpụkpụ navicular, ma MRI nwere. enweghị ihe doro anya pụtara n'ịchọpụta ọgwụgwọ nke mgbaji ahụ.
Ngosipụta na contraindications:
Navicular osteochondral nounion na nrụrụ gbadara azụ na DISI; MRI na-egosi ischemic necrosis nke navicular ọkpụkpụ, intraoperative loosening nke tourniquet na chọpụtara nke mgbaji gbajiri njedebe nke navicular ọkpụkpụ ka na-acha ọcha sclerotic ọkpụkpụ; ọdịda nke mbụ wedge ọkpụkpụ grafting ma ọ bụ ịghasa esịtidem fixing chọrọ nnukwu VGB structural grafting (1cm3). nchọpụta mbụ ma ọ bụ intraoperative nke ọrịa ogbu na nkwonkwo nke nkwonkwo radial carpal; ọ bụrụ na nnukwu ọrịa navicular malunion na osteoarthritis na-ada ada, mgbe ahụ, a ga-achọ nkwụsị aka aka, navicular osteotomy, fusion quadrangular, proximal carpal osteotomy, mkpokọta carpal fusion, wdg, nwere ike ịchọrọ; navicular malunion, proximal necrosis, ma na nkịtị navicular ọkpụkpụ morphology (eg, na-abụghị nke navicular mgbaji mgbaji na ọbara dara ogbenye na-enyefe na okporo osisi dị nso); Mbelata nke navicular malunion na-enweghị osteonecrosis. (Enwere ike iji 1,2-ICSRA mee ihe dị ka ihe nnọchi maka flap radius distal).
Anatomi etinyere
A na-enye MFC VBG site n'ọtụtụ obere arịa trophoblastic interosseous interosseous (pụtara 30, 20-50), nke nwere oke ọbara dị n'azụ dị ala karịa condyle femoral medial (pụtara 6.4), na-esote nke dị elu (pụtara 4.9) ( Foto 2). A na-ebute arịa ndị a trophoblastic site na akwara na-agbadata geniculate (DGA) na / ma ọ bụ akwara medial geniculate artery (SMGA), nke bụ ngalaba nke akwara femoral nke elu nke na-ebutekwa akwara akwara, musculocutaneous, na / ma ọ bụ ngalaba akwara saphenous. . DGA sitere na akwara femoral dị elu dị nso na etiti etiti nke medial malleolus, ma ọ bụ n'ebe dị anya nke 13.7 cm dị nso na elu articular (10.5-17.5 cm), na nkwụsi ike nke alaka ahụ bụ 89% na ụdị cadaveric. (Foto nke 3). DGA sitere na akwara femoral dị elu na 13.7 cm (10.5 cm-17.5 cm) dị nso na etiti malleolus fissure ma ọ bụ dị nso na elu articular, nke nwere ụdị cadaveric na-egosi nkwụsi ike alaka 100% na dayameta nke ihe dịka 0.78 mm. Ya mere, ma DGA ma ọ bụ SMGA na-anabata, ọ bụ ezie na nke mbụ dị mma maka tibiae n'ihi ogologo na dayameta nke ụgbọ ahụ.
Fig. 2. Nkesa anọ nke MFC trophoblast arịa dị n'ahịrị kwụ ọtọ n'etiti semitendinosus na ligament medial ligament A, akara nke nnukwu trochanter B, akara nke elu elu nke patella C, akara nke meniscus D.
Ọnụọgụ 3. MFC vaskụla anatomy: (A) alaka ndị dịpụrụ adịpụ na MFC trophoblastic vascular anatomy, (B) Ebe dị anya sitere na vaskụla sitere na eriri nkwonkwo.
Ịwa ahụ
A na-edobe onye ọrịa n'okpuru mgbakasị ahụ n'ozuzu ya n'ọnọdụ dị elu, na-etinye akụkụ ahụ emetụtara na tebụl ịwa ahụ aka. N'ozuzu, a na-ewepụ ọkpụkpụ ọkpụkpụ onye na-enye onyinye site na condyle medial medial femoral condyle nke ipsilateral, nke mere na onye ọrịa ahụ nwere ike ịkwaga na crutches mgbe a wachara ya ahụ. A pụkwara ịhọrọ ikpere na-emegiderịta onwe ya ma ọ bụrụ na enwere akụkọ ihe mere eme nke trauma ma ọ bụ ịwa ahụ gara aga n'otu akụkụ nke ikpere. A na-atụgharị ikpere na hip na-atụgharị n'èzí, a na-etinyekwa njem nlegharị anya n'akụkụ elu na nke ala. Usoro ịwa ahụ bụ ụzọ Russe gbatịrị agbatị, na mbepụ na-amalite 8 cm dị nso na ọwara carpal transverse wee gbatịa site na radial nsọtụ nke radial flexor carpi radialis tendon, wee na-apịaji na ọwara carpal transverse chere ihu isi mkpịsị aka ya. , na-ejedebe na ọkwa nke nnukwu trochanter. A na-agbaji n'ọbọ akwara nke akwara radial longissimus na akwara na-adọta ya n'azụ, a na-ekpughekwa ọkpụkpụ azụ azụ site na nhụsianya dị nkọ n'akụkụ radial lunate na radial navicular head ligaments, na-eji nlezianya kewapụ anụ ahụ dị nro dị nro nke ọkpụkpụ azụ iji kwe ka ọ dị mma. Mkpughe ọzọ nke ọkpụkpụ navicular (Fig 4). Kwado mpaghara nke enweghị njikọ, ogo cartilage articular na ogo ischemia nke ọkpụkpụ navicular. Mgbe ịtọpụ njem nlegharị anya ahụ, lelee oghere dị nso nke ọkpụkpụ navicular maka ọbara ọgbụgba iji chọpụta ma enwere ischemic necrosis. Ọ bụrụ na ejikọtaghị necrosis navicular na radial carpal ma ọ bụ ọrịa ogbu na nkwonkwo intercarpal, enwere ike iji MFC VGB mee ihe.
Ọgụgụ 4. Ụzọ ịwa ahụ nke Navicular: (A) Mwapụ ahụ na-amalite 8 cm dị nso na ọwara carpal transverse ma gbasaa radial nsọtụ nke radial flexor carpi radialis tendon na akụkụ dị anya nke mbepụ, nke a na-apịaji n'akụkụ isi nke isi mkpịsị aka ahụ. na transverse carpal ọwara. (B) A na-agbaji n'ọbọ akwara nke eriri ogologo radial longissimus na akaị ya na-adọkpụ ya, a na-ekpughekwa ọkpụkpụ navicular site na mgbasa dị nkọ n'akụkụ radial lunate na radial navicular head ligaments. (C) Chọpụta mpaghara nkwụsị osseous navicular.
A na-eme mbepụ ogologo 15-20 cm dị nso n'ahịrị nkwonkwo ikpere n'akụkụ azụ azụ nke anụ ahụ femoral medial, na anụ ahụ na-atụgharị n'ihu iji kpughee ọbara MFC (Fig 5) . A na-enyekarị MFC ọbara ọbara. site na ngalaba articular nke DGA na SMGA, na-ewerekarị ngalaba nkwonkwo buru ibu nke DGA na vein na-eso ya. A na-atọhapụ pedicle vaskụla nso, na-elezi anya iji chebe periosteum na arịa trophoblastic n'elu ọkpụkpụ.
Ọnụọgụ 5. Ịwa ahụ na MFC: (A) A na-eme mbepụ ogologo 15-20 cm dị nso n'akụkụ azụ nke ụbụrụ femoral medial site na eriri nkwonkwo ikpere. (B) A na-eweghachi ahụ ike ahụ n'ihu iji kpughee ọbara MFC.
Nkwadebe nke ọkpụkpụ navicular
A ghaghị imezi nrụrụ DISI navicular na mpaghara ọkpụkpụ ọkpụkpụ osteochondral a kwadebere tupu etinye ya site n'ịgbanwe nkwojiaka n'okpuru fluoroscopy iji weghachite akụkụ radial lunate nkịtị (Nyocha 6). A na-agbapu 0.0625-ụkwụ (ihe dị ka 1.5-mm) Kirschner pin na-agbapụ kpamkpam site na dorsal ruo metacarpal iji dozie nkwonkwo radial lunate, na oghere navicular malunion na-ekpughe mgbe a na-agbatị aka aka. A kpochapụrụ oghere mgbaji ahụ site na anụ ahụ dị nro ma jiri mgbasa ozi gbasaa ọzọ meghee ya. A na-eji obere ihe na-emegharị ihe na-eme ka ọkpụkpụ na-eme ka ọkpụkpụ na-eme ka ọkpụkpụ na-eme ka ọkpụkpụ na-eme ka ọkpụkpụ na-eme ka ọ dị ka ihe dị n'ime akụkụ anọ karịa wedge, nke chọrọ ka a na-edozi oghere navicular na oghere dị ukwuu n'akụkụ palmar karịa n'akụkụ azụ. Mgbe emepechara oghere ahụ, a na-atụle ntụpọ ahụ na akụkụ atọ iji chọpụta oke ọkpụkpụ ọkpụkpụ, nke na-abụkarị 10-12 mm n'ogologo n'akụkụ niile nke aka.
Ọnụọgụ 6. Ndozi nke nrụrụ gbadatara azụ nke navicular, na mgbanwe fluoroscopic nke nkwojiaka iji weghachi nhazi nke radial-ọnwa nkịtị. A 0.0625-ụkwụ (ihe dị ka 1.5-mm) Kirschner pin na-agbapụ kpamkpam site na dorsal ruo metacarpal iji dozie nkwonkwo radial lunate, na-ekpughe oghere navicular malunion ma na-eweghachi ịdị elu nke ọkpụkpụ navicular mgbe nkwojiaka na-agbatị, na nha nha. oghere na-ebu amụma nha nke flap ga-adị mkpa ka egbochie ya.
Osteotomy
A na-ahọrọ mpaghara vaskụla nke etiti femoral condyle dị ka ebe a na-ewepụ ọkpụkpụ, na ebe ọkpụkpụ ọkpụkpụ na-egosipụta nke ọma. Kpachara anya ka ị ghara imerụ njikọ nke etiti ahụ. A na-egbutu periosteum ahụ, a na-egbutukwa ọkpụkpụ akụkụ anọ nke nha kwesịrị ekwesị maka ọkpụkpụ a na-achọsi ike na-eme ka ọkpụkpụ na-emegharị ahụ, na-egbutu ọkpụkpụ nke abụọ na 45 ° n'otu akụkụ iji hụ na iguzosi ike n'ezi ihe nke flap (Fig 7). 7). Ekwesịrị ịkpachapụ anya ka ị ghara ikewapụ periosteum, ọkpụkpụ cortical, na ọkpụkpụ ịkagbu nke flap. Ekwesịrị ịhapụ njem nlegharị anya nke dị ala iji hụ na ọbara na-erugharị site na flap, na pedicle vaskụla kwesịrị ịtọhapụ ya nso maka opekata mpe 6 cm iji kwe ka anastomosis vaskụla na-esote. Ọ bụrụ na ọ dị mkpa, enwere ike ịga n'ihu na obere ọkpụkpụ nke kagbuo n'ime condyle femoral. Nrụrụ condylar femoral na-ejupụta na ihe ngbanwe ọkpụkpụ, a na-ewepụkwa mbepụ ahụ ma mechie oyi akwa site na oyi akwa.
Ọgụgụ 7. MFC ọkpụkpụ mwepu. (A) A na-akara ebe osteotomy zuru ezu iji mejupụta oghere mmiri mmiri, a na-akpụpụta periosteum ahụ, na ọkpụkpụ akụkụ akụkụ anọ nke nha kwesịrị ekwesị maka flap a chọrọ ka a na-eji ihe ntugharị na-emegharị. (B) A na-egbutu ọkpụkpụ nke abụọ n'otu akụkụ na 45 ° iji hụ na iguzosi ike n'ezi ihe nke flap ahụ.
Ịkụnye flap na ndozi
A na-akpụzi ọkpụkpụ ọkpụkpụ n'ụdị kwesịrị ekwesị, na-elezi anya ka ọ ghara ịpịkọta pedicle vaskụla ma ọ bụ yipụ periosteum. A na-akụnye flap ahụ nke ọma n'ime mpaghara ntụpọ nke ọkpụkpụ azụ azụ, na-ezere ịkwa ụda, ma jiri skru navicular dozie ya. A na-elezi anya iji hụ na akụkụ ọbụ aka nke ngọngọ ọkpụkpụ etinyere na akụkụ palmar nke ọkpụkpụ azụ azụ ma ọ bụ na ọ nwere ntakịrị nkụda mmụọ iji zere nkwụsị. A na-eme fluoroscopy iji gosi na ọkpụkpụ ọkpụkpụ navicular, akara ike na ọnọdụ ịghasa. Anastomose the vascular flap artery na radial artery end to side and the venous tip to the radial artery vein vein end to end (Figure 8). A na-arụzi capsule nkwonkwo, mana a na-ezere pedicle vaskụla.
Ihe osise 8. Mkpọnye ọkpụkpụ ọkpụkpụ, nhazi, na anastomosis vaskụla. A na-akụnye ọkpụkpụ ọkpụkpụ ahụ nke ọma n'ime mpaghara ntụpọ ọkpụkpụ navicular ma dozie ya na skru navicular oghere ma ọ bụ ntụtụ Kirschner. A na-elezi anya na akụkụ metacarpal nke ngọngọ ọkpụkpụ etinyere na-adaba na akụkụ metacarpal nke ọkpụkpụ azụ azụ ma ọ bụ nke dara mbà n'obi iji zere nkwụsị. A na-eme anastomosis nke akwara vaskụla vaskụla akwara na akwara radial na njedebe na njedebe, a na-emekwa isi akwara na vein nke radial artery vein na njedebe na njedebe.
Ndozigharị arụ ọrụ mgbe arụchara ọrụ ahụ
Oral aspirin 325 mg kwa ụbọchị (maka otu ọnwa), a na-ekwe ka ọ dị arọ nke akụkụ ahụ emetụtara mgbe ịwachara ahụ, breeki ikpere nwere ike ibelata ahụ erughị ala nke onye ọrịa, dabere n'ikike onye ọrịa nwere ịgagharị n'oge kwesịrị ekwesị. Nkwado ndị na-akwado otu eriri nwere ike ibelata ihe mgbu, mana nkwado ogologo oge nke crutches adịghị mkpa. E wepụrụ stitches ahụ izu 2 mgbe a wachara ya ahụ ma debe Muenster ma ọ bụ ogologo ogwe aka ruo nkedo mkpịsị aka ya n'ime ebe izu atọ. Mgbe nke ahụ gasịrị, a na-eji obere ogwe aka iji nweta ihe nkedo ruo mgbe mgbaji ahụ ga-agwọta. A na-ewere ụzarị X-ray na etiti izu 3-6, CT kwadoro ọgwụgwọ mgbaji. Mgbe nke ahụ gasịrị, a ghaghị ịmalite nke nta nke nta nke nta nke nta nke nta nke nta nke nta na-arụ ọrụ na nke na-adịghị ike, na ike na ugboro ole nke mmega ahụ kwesịrị iji nwayọọ nwayọọ mụbaa.
Nnukwu nsogbu
Isi nsogbu nke nkwonkwo ikpere gụnyere mgbu ikpere ma ọ bụ mmerụ ahụ akwara. Mgbu ikpere na-abụkarị n'ime izu isii mgbe a wachara ya ahụ, ọ nweghịkwa mmetụta uche ma ọ bụ neuroma na-egbu mgbu n'ihi mmerụ ahụ akwara saphenous. Isi nsogbu nkwojiaka gụnyere mgbagha ọkpụkpụ, mgbu, isi ike nkwonkwo, adịghị ike, ọrịa ogbu na nkwonkwo na-aga n'ihu nke radial wrist ma ọ bụ ọkpụkpụ intercarpal, na ihe ize ndụ nke periosteal heterotopic ossification a kọkwara.
Medial Femoral Condyle Vascularised ọkpụkpụ n'efu maka Scaphoid Nonunions na Proximal Pole Avascular Necrosis na Carpal Collapse
Oge nzipu: Mee-28-2024
