Indwara ya malariya ibaho hafi 5-15% yimvune zose zikaze zamagufa yo mu mazi, hamwe na nérosose yo mu mazi iba hafi 3%. Impamvu zishobora gutera malariya zo mu mazi zirimo gusuzumwa cyangwa gutinda gusuzumwa, kuba hafi yumurongo wavunitse, kwimuka kurenze mm 1, no kuvunika hamwe no kudahungabana kwa karpal. Iyo itavuwe neza, osteochondral yo mu mazi ikunze guhuzwa na arthrite ihahamuka, izwi kandi nka osteochondral navicular hamwe na osteoarthritis isenyuka.
Gufata amagufwa hamwe cyangwa udafite flapulaire flapulaire irashobora gukoreshwa mukuvura osteochondral navicular. Nyamara, ku barwayi barwaye osteonecrosis ya pole yegeranye y’amagufwa yo mu mazi, ibisubizo byo guteranya amagufwa nta mitsi y'amaraso ntibishimishije, kandi igipimo cyo gukiza amagufwa ni 40% -67% gusa. Ibinyuranye, igipimo cyo gukiza cyamagufwa yamagufa hamwe nuduce twa vasculaire irashobora kugera kuri 88% -91%. Amagufa yingenzi yimitsi yamagufa mubikorwa byubuvuzi harimo 1,2-ICSRA-yandikiwe na radiyo ya kure ya radiyo, igufwa ryamagufwa + imitsi ya bundle yatewe, palmar radius flap, igufwa rya iliac igufwa ryubusa, hamwe na femorale femoral condylar igufwa ryamagufwa (MFC VBG), nibindi. Ubuntu MFC VBG bwerekanwe ko bugira akamaro mukuvura imvune zo mu mazi hamwe no gusenyuka kwa metacarpal, kandi MFC VBG ikoresha ishami rya arctular ya arteri yimivi imanuka nkishami rikuru rya tropique. Ugereranije n’ibindi bikoresho, MFC VBG itanga inkunga ihagije kugirango igarure imiterere isanzwe yamagufa yo mu mazi, cyane cyane mu kuvunika kwa osteochondrosis yo mu mazi hamwe no kunanirwa inyuma (Ishusho 1). Mu kuvura osteochondral osteonecrosis yo mu mazi hamwe no gusenyuka kwa karpal igenda itera imbere, bivugwa ko 1,2-ICSRA yandikiwe na radiyo ya radiyo yerekana ko ifite amagufwa yo gukira amagufwa angana na 40% gusa, mu gihe MFC VBG ifite amagufwa yo gukiza amagufwa 100%.
Igicapo 1. Kuvunika amagufwa yo mu mazi afite ubumuga "bwunamye inyuma", CT yerekana guhagarika kuvunika hagati yamagufwa yo mu mazi ku nguni ya 90 °.
Gutegura mbere yo gutangira
Nyuma yo gusuzuma umubiri ku kuboko kwanduye, hagomba gukorwa ubushakashatsi bwerekana amashusho kugirango hamenyekane urugero rwo gusenyuka kwamaboko. Amaradiyo yo mu kibaya ni ingirakamaro mu kwemeza aho yavunitse, urwego rwo kwimuka, hamwe no kuba resorption cyangwa sclerose yimpera yamenetse. Amashusho yinyuma yinyuma akoreshwa mugusuzuma kugwa kwamaboko, ihungabana ryimyanya yintoki (DISI) ukoresheje igipimo cyuburebure bwikiganza (uburebure / ubugari) bwa .51.52 cyangwa inguni ya radiyo irenga 15 °. MRI cyangwa CT irashobora gufasha mugupima malalignment yamagufa yo mu mazi cyangwa osteonecrosis. Iradiyo yegeranye cyangwa oblique sagittal CT yamagufa yo mu mazi afite inguni yo mu mazi> 45 ° yerekana ko igabanuka ryamagufwa yo mu mazi, azwi ku izina rya "kwunama inyuma yubumuga" .MRI T1, T2 ikimenyetso gito cyerekana necrosis yamagufa yo mu mazi, ariko MRI nta kamaro igaragara muguhitamo gukira kuvunika.
Ibyerekana no kubirwanya:
Navicular osteochondral nonunion hamwe yunamye inyuma yubumuga na DISI; MRI yerekana ischemic necrosis yo mu magufa yo mu mazi, kurekura imikoranire ya tourniquet no kwitegereza kuvunika kuvunika kumagufwa yo mu mazi biracyari igufwa ryera rya sklerotike; kunanirwa kwambere amagufwa ya wedge cyangwa kugorora imbere imbere bisaba guhuza amagufwa manini ya VGB (＞ 1cm3). ubushakashatsi mbere yo gutangira cyangwa gukorana kwa osteoarthritis ya radiyo karpal ifatanye; niba habaye malunion ikomeye yo mu mazi hamwe no kugwa kwa osteoarthritis yabayeho, noneho kubika amaboko, osteotomy yo mu mazi, guhuza impande enye, guhuza carpal osteotomy, hafi ya carpal osteotomy, guhuza karpal yose, nibindi, birashobora gukenerwa; malicularion malariya, necrosis yegeranye, ariko hamwe namagufwa asanzwe yimitsi yo mumaguru (urugero, kuvunika kwamato kutimuwe hamwe no gutanga amaraso mabi kuri pole yegeranye); kugabanya malariya yo mu mazi idafite osteonecrosis. (1,2-ICSRA irashobora gukoreshwa mugusimbuza radiyo ya kure).
Gukoresha Anatomy
MFC VBG itangwa nuduce duto duto duto twa trophoblastique (bivuze 30, 20-50), hamwe n'amaraso menshi cyane ari inyuma yinyuma ya condyle yo hagati (bivuze 6.4), ikurikirwa no hejuru (bivuze 4.9) (Ishusho 2). Izi miyoboro ya trophoblastique yatanzwe ahanini na arteri yamanuka (DGA) na / cyangwa arteriire ya medial geniculate arteriire (SMGA), ishami ryumuvuduko wimitsi wigitsina gore nawo utanga amashami yimitsi ya articular, musculocutaneous, na / cyangwa saphenous nervice. DGA yakomotse kuri arterial femorale arterique yegeranye no hagati ya malleolus yo hagati, cyangwa ku ntera ya cm 13.7 yegeranye n'ubuso bwa arctular (cm 10.5-17.5 cm), kandi ituze ryishami ryari 89% mubigereranyo bya cadaveric (Ishusho 3). DGA ikomoka ku muyoboro w'igitsina gore utagaragara kuri cm 13,7 (cm 10.5 cm-17.5 cm) hafi ya feri ya malleolus yo hagati cyangwa yegeranye n'ubuso bwa arctular, hamwe na cadaveric yerekana 100% ishami rihamye hamwe na diameter ya mm 0,78. Kubwibyo, haba DGA cyangwa SMGA biremewe, nubwo iyambere ikwiranye na tibiae kubera uburebure na diameter yubwato.
Igishushanyo cya 2. Ikwirakwizwa rya kane rya kane ya MFC trophoblast yamato kumurongo utambitse hagati ya semitendinosus na ligamente yingwate yo hagati A, umurongo wa trocanter nini B, umurongo winkingi isumba izindi ya patella C, umurongo wa meniskus imbere D.
Igishushanyo 3. Anatomiya ya MFC: (A) Amashami adasanzwe hamwe na anatomiya ya MFC trophoblastique, (B) Intera yinkomoko yimitsi iva kumurongo
Kubaga
Umurwayi ashyizwe munsi ya anesthesia muri rusange mumwanya wa supine, hamwe n'ingingo zanduye zashyizwe kumeza yo kubaga intoki. Mubisanzwe, umuterankunga wamagufwa yakuwe mubice bibiri bya medial femoral condyle, kugirango umurwayi ashobore kugenda afite inkoni nyuma yo kubagwa. Ivi rinyuranyije naryo rishobora guhitamo niba hari amateka yihungabana ryabanje cyangwa kubagwa kuruhande rumwe rwivi. Ikivi kiranyeganyega kandi ikibuno kizunguruka hanze, kandi amarushanwa akoreshwa kumurongo wo hejuru no hepfo. Uburyo bwo kubaga bwari uburyo bwagutse bwa Russe, hamwe no gutemagura bitangirira kuri cm 8 hafi yumurongo wa carpal transvers no kwaguka kure kuva kuruhande rwa radiyo ya radiyo flexor carpi radialis tendon, hanyuma ukazenguruka kumurongo wa karpal unyura ugana munsi yintoki, bikarangirira kurwego rwumudugudu munini. Icyatsi cya tendon ya radial longissimus tendon irashwanyaguritse kandi igashushanywa ulnarly, kandi igufwa ryo mu mazi ryerekanwa no gutandukana gukabije kumutwe wa radial lunate na radial navicular head ligaments, hamwe no gutandukanya witonze uturemangingo tworoheje twa magufa yo mu mazi kugira ngo tumenye neza igufwa ryo mu mazi (Ishusho 4). Emeza agace ko kudahuza, ubwiza bwa karitsiye ya articular hamwe nurwego rwa ischaemia yamagufwa yo mu mazi. Nyuma yo kurekura irushanwa, reba inkingi yegeranye yamagufa yo mu mazi kugirango amaraso atemba kugirango umenye niba hari isekemike ya nérosose. Niba necrosis yo mu mazi idafitanye isano na radiyo karpal cyangwa arthritis intercarpal, MFC VGB irashobora gukoreshwa.
Igishushanyo 4. Uburyo bwo kubaga mu mazi: (A) Gutemagura bitangira cm 8 hafi yumurongo wa karpal transvers kandi bikagura impande ya radiyo ya radiyo flexor carpi radialis ikunda kugera ku gice cyitaruye cy’igice, kizingiye ku nsi y’urutoki kuri tuneli ya karpal. . (C) Menya agace ka osicular osseous guhagarara.
Uburebure bwa cm 15-20 bukozwe hafi yumurongo uhuza ivi kumupaka winyuma wimitsi ya femorale yo hagati, kandi imitsi isubizwa inyuma kugirango yerekane amaraso ya MFC (Igicapo 5) .Amaraso ya MFC mubisanzwe atangwa namashami ya arctique ya DGA na SMGA, mubisanzwe bifata ishami rinini rya DGA hamwe nu mitsi ijyanye nayo. Imitsi y'amaraso irekurwa hafi, yitondera kurinda periosteum hamwe nimiyoboro ya trophoblastique hejuru yamagufwa.
Igicapo 5. Kubagwa kwa MFC: (A) Uburebure bwa cm 15-20 bukozwe hafi yumupaka winyuma wimitsi yo hagati yumugore kuva kumurongo ufatanye. (B) Imitsi isubizwa inyuma kugirango igaragaze amaraso ya MFC .。
Gutegura amagufwa yo mu mazi
Ubumuga bwa DISI bwo mu mazi bugomba gukosorwa kandi agace k'amagufwa ya osteochondral yateguwe mbere yo guterwa muguhindura intoki munsi ya fluoroscopi kugirango ugarure inguni isanzwe ya radiyo (Ishusho 6). Uburebure bwa metero 0.0625 (hafi 1,5-mm) Kirschner pin iracukurwa muburyo butandukanye kuva dorsal kugera metacarpal kugirango ikosore ingingo ya radial lunate, kandi ikinyuranyo cya malunion yo mumato kigaragara mugihe ukuboko kugororotse. Umwanya wavunitse wahanaguweho imyenda yoroshye hanyuma ukomeza gufungurwa ukoresheje icyapa. Agace gato gasubiranamo gakoreshwa mu kuringaniza igufwa no kwemeza ko igipapuro cyatewe gisa cyane n’imiterere y'urukiramende kuruta uruzitiro, bisaba ko icyuho cyo mu mazi cyakemurwa n’ikinyuranyo kinini kuruhande rwa palmar kuruta kuruhande rwa dorsal. Nyuma yo gufungura icyuho, inenge ipimwa mubipimo bitatu kugirango hamenyekane urugero rwigufwa ryamagufwa, ubusanzwe rifite mm 10-12 z'uburebure kumpande zose.
Igicapo 6. Gukosora ubumuga bwumugongo bwunamye bwamazi, hamwe na fluoroscopique ihindagurika yintoki kugirango igarure imirongo isanzwe ya radial-ukwezi. Uburebure bwa metero 0.0625 (hafi 1,5-mm) Kirschner pin iracukurwa muburyo butandukanye kuva dorsal kugera metacarpal kugirango ikosore ingingo ya radial lunate ihuriweho, igaragaze icyuho cya malunion yo mu mazi kandi igarura uburebure busanzwe bwamagufwa yo mu mazi mugihe ukuboko kugororotse, hamwe nubunini bwikinyuranyo cyerekana ubunini bwikibabi kizakenera gufatwa.
Osteotomy
Agace ka vascularised ya medial femoral condyle yatoranijwe nkahantu ho gukuramo amagufwa, naho agace gakuramo amagufwa kagaragajwe bihagije. Witondere kudakomeretsa ingwate yo hagati. Periosteum irashwanyagujwe, kandi igufwa ry'urukiramende rw'urukiramende rufite ubunini bukwiranye n'igitereko cyifuzwa rwaciwe hamwe n'icyuma gisubiranamo, hamwe n'amagufwa ya kabiri yaciwe kuri 45 ° ku ruhande rumwe kugira ngo uburinganire bwacyo (Ishusho 7). 7). Ugomba kwitondera kudatandukanya periosteum, amagufwa ya cortical, hamwe namagufwa ya kanseri. Urugendo rwo hepfo rugomba kurekurwa kugirango harebwe amaraso atembera mu gihimba, kandi pedicle y'amaraso igomba kurekurwa hafi ya cm 6 kugirango habeho anastomose y'amaraso. Nibiba ngombwa, agace gato k'amagufwa ya kanseri arashobora gukomeza muri condyle femorale. Inenge ya femoral condylar yuzuyemo igifu gisimbuza amagufwa, kandi incike irakama kandi igafungwa kumurongo.
Igicapo 7. Gukuraho amagufwa ya MFC. . (B) Igice cya kabiri cyamagufa yaciwe kuruhande rumwe kuri 45 ° kugirango harebwe ubusugire bwikibabi.
Gushyira flap no gukosora
Igufwa ryamagufwa yatunganijwe muburyo bukwiye, yitondera kudahagarika imitsi y'amaraso cyangwa kwambura periosteum. Igipapuro cyatewe buhoro buhoro mu gice cy’amagufwa yo mu mazi, yirinda gukomeretsa, kandi bigashyirwaho n’imigozi idafite umwobo. Hafashwe ingamba zo kureba niba imikindo yimikindo yatewe amagufwa yatembagaye hamwe n’imikindo y’amagufwa yo mu mazi cyangwa ko yarihebye gato kugirango yirinde kwangirika. Fluoroscopy yakozwe kugirango hemezwe amagufwa ya morfologiya, umurongo w'imbaraga n'umwanya wa screw. Anastomose imiyoboro y'amaraso iva mu mitsi ya radiyo irangirira ku mpande hamwe n'umuyoboro w'amaraso ugana imiyoboro y'amaraso ya radiyo iherekeza ikarangira (Ishusho 8). Capsule ihuriweho irasanwa, ariko pedicle yimitsi iririndwa.
Igicapo 8. Gutera amagufwa, gukosorwa, hamwe na anastomose yimitsi. Igufwa ryamagufwa ryinjijwe buhoro buhoro mugace k’amagufwa yo mu mazi kandi agashyirwaho n’imigozi idafite aho ihuriye cyangwa pin ya Kirschner. Witondere ko metacarpal margin yumutwe watewe amagufwa ihindagurika hamwe na metacarpal margin yamagufwa yo mu mazi cyangwa yihebye byoroheje kugirango yirinde kwangirika. Anastomose yimitsi yimitsi iva kumitsi ya radiyo yakozwe irangira irangiye, kandi imitsi yimitsi iva kumitsi ya radiyo ya mugenzi we yarakozwe irangira.
Nyuma yo gusubira mu buzima busanzwe
Asipirine yo mu kanwa 325 mg kumunsi (ukwezi 1), biremereye nyuma yo kubyara ibiro byanduye byanduye, gufata feri birashobora kugabanya uburwayi bwumurwayi, bitewe nubushobozi bwumurwayi bwo kugenda mugihe gikwiye. Inkunga ihuriweho nigitereko kimwe irashobora kugabanya ububabare, ariko inkunga yigihe kirekire yinkoni ntabwo ikenewe. Ubudodo bwakuweho nyuma yibyumweru 2 nyuma yo kubagwa hanyuma Muenster cyangwa ukuboko kurekure kurutoki babikwa mu byumweru 3. Nyuma yibyo, ukuboko kugufi kurutoki gukoreshwa kugeza igihe kuvunika gukize. X-imirasire ifatwa mugihe cyicyumweru 3-6, kandi gukira kuvunika byemejwe na CT. Nyuma yibyo, ibikorwa bikora kandi byoroshye guhinduka no kwagura ibikorwa bigomba gutangira buhoro buhoro, kandi ubukana ninshuro zimyitozo ngororamubiri bigomba kwiyongera buhoro buhoro.
Ingorane zikomeye
Ingorane nyamukuru zifata ivi zirimo kubabara ivi cyangwa gukomeretsa imitsi. Ububabare bw'amavi bwabaye cyane cyane mu byumweru 6 nyuma yo kubagwa, kandi nta gutakaza ibyiyumvo cyangwa neuroma ibabaza bitewe no gukomeretsa imitsi ya saphenous. Ingorane nyamukuru z’ukuboko kwarimo kunanirwa amagufwa kunanirwa, kubabara, kunangira ingingo, intege nke, osteoarthritis igenda itera intoki ya radial cyangwa amagufwa ya intercarpal, kandi hashobora no kuvugwa ibyago byo guterwa na periosteal heterotopic.
Ubuntu bwa Medial Femoral Condyle Vascularised Amagufwa yo Gufata Scaphoid Nonunions hamwe na Proximal Pole Avascular Necrosis na Carpal Gusenyuka
Igihe cyo kohereza: Gicurasi-28-2024
