Indwara ya Navicular malinion ibaho hafi 5-15% by'imvune zose zikomeye ku igufwa rya navicular, aho navicular necrosis ibaho hafi 3%. Ibintu bishobora gutera navicular malinion birimo gutinda gusuzuma indwara, kuba umurongo wavunitse wegereye cyane, kwimuka kurenza mm 1, no kuvunika bitewe no kudakomera kwa carpal. Iyo itavuwe, navicular osteochondral nonunion ikunze kwibasirwa na traumatique, izwi kandi nka navicular osteochondral nonunion hamwe na osteoarthritis igwa.
Guteranya amagufwa hakoreshejwe cyangwa nta ruhushya rwo guteranya imitsi bishobora gukoreshwa mu kuvura indwara ya osteochondral idafite aho ihuriye. Ariko, ku barwayi bafite osteonecrosis y'umugongo wa hafi w'igufwa rya navicular, ibisubizo byo guteranya amagufwa nta pfundo ry'imitsi ntibishimishije, kandi igipimo cyo gukira kw'amagufwa ni 40%-67 gusa. Ibinyuranye n'ibyo, igipimo cyo gukira kw'udupfundo tw'amagufwa hakoreshejwe impuzamitsi gishobora kugera kuri 88%-91%. Udupfundo tw'amagufwa tw'imitsi dukomeye mu buvuzi burimo 1,2-ICSRA-tipped distal radius flap, improvement y'amagufwa + vascular bundle implant, palmar radius flap, free iliac bone flap ifite impuzamitsi, na medial femoral condylar bone flap (MFC VBG), n'ibindi. Ibisubizo byo guteranya amagufwa hakoreshejwe impuzamitsi birashimishije. MFC VBG y'ubuntu byagaragaye ko igira akamaro mu kuvura imvune za navicular hamwe no kugwa kwa metacarpal, kandi MFC VBG ikoresha ishami rya articular ry'imitsi y'amavi imanuka nk'ishami rikuru rya trophic. Ugereranyije n'izindi nyundo, MFC VBG itanga inkunga ihagije mu miterere kugira ngo igarure imiterere isanzwe y'igufwa rya navicular, cyane cyane mu gihe cy'ivunika rya navicular osteochondrosis hamwe n'ubumuga bw'umugongo buhagaze (Ishusho ya 1). Mu kuvura osteonecrosis ya navicular osteochondral hamwe n'ivunika rya carpal rikomeje, byagaragaye ko impundu ya distal radius ya 1,2-ICSRA ifite igipimo cyo gukira kw'amagufwa cya 40% gusa, mu gihe MFC VBG ifite igipimo cyo gukira kw'amagufwa cya 100%.
Ishusho ya 1. Gucika kw'igufwa ry'inyuma hamwe n'ubumuga "bwagoswe", CT igaragaza agace kavunitse hagati y'amagufwa y'inyuma ku nguni ya hafi 90°.
Kwitegura mbere yo kubagwa
Nyuma yo gusuzuma umubiri w'ukuboko kwangiritse, hagomba gukorwa inyigo zo gupima urwego rw'ukuboko kwangiritse. Isuzuma rya radiografiya risanzwe ni ingirakamaro mu kwemeza aho kwangiritse, urwego rwo kwimuka, ndetse no kuba hari aho impera yavunitse yacitse cyangwa ihindagurika. Amashusho y'imbere y'inyuma akoreshwa mu gusuzuma kugwa kw'ukuboko, kudahinduka kw'ukuboko kw'inyuma (DISI) hakoreshejwe uburebure bw'ukuboko bwahinduwe (uburebure/ubugari) bwa ≤1.52 cyangwa inguni y'urumuri ya radial irenga 15°. MRI cyangwa CT bishobora gufasha gusuzuma imiterere mibi y'igufwa rya navicular cyangwa osteonecrosis. Isuzuma rya radiografiya cyangwa CT ya oblique sagittal y'igufwa rya navicular ifite inguni ya navicular >45° bigaragaza ko igufwa rya navicular rigabanutse, bizwi nka "ubusembwa bw'umugongo wometse". MRI T1, ikimenyetso gito cya T2 kigaragaza ko igufwa rya navicular ryacitse, ariko MRI nta kamaro kagaragara ifite mu kumenya gukira kw'igufwa ryacitse.
Ibimenyetso n'ibibujijwe:
Uruhu rw'igufwa rya osteochondral rudafite aho ruhuriye hamwe rufite ubumuga bw'umugongo bupfutse na DISI; MRI igaragaza isheshi y'igufwa rya osteochondral, kurekura tourniquet mu gihe cyo kubaga no kureba aho ryavunitse impera y'igufwa rya osteochondral ryavunitse ikiri igufwa ryera; kunanirwa kw'igufwa rya mbere cyangwa gushyiramo screw imbere bisaba ko hashyirwaho VGB nini (> 1cm3). Mbere yo kubagwa cyangwa mu gihe cyo kubaga hagaragaye osteochondral y'urugingo rwa radial carpal; niba habayeho osteochondral ikomeye hamwe na osteochondral igwa, hashobora kuba ngombwa ko habaho ihinduka ry'urutoki, osteochondral ya osteochondral, quadrangular fusion, osteochondral carpal osteotomy, fusion ya carpal yose, nibindi; osteochondral ya osteochondral, necrosis ya proximal, ariko hamwe n'imiterere isanzwe y'amagufwa ya osteochondral (urugero: kuvunika kwa osteochondral kwa osteochondral hamwe n'amaraso adahagije agera ku gice cya proximal pole); kugabanuka kwa osteonecrosis ya osteonecrosis. (1,2-ICSRA ishobora gukoreshwa nk'igisimbuzo cy'urukiramende rwa distal radius).
Isesengura ry'imiterere y'umubiri (anatomie)
MFC VBG itangwa n'imitsi mito ya trophoblastic ifite impande (impuzandengo ya 30, 20-50), aho amaraso menshi cyane ari inyuma y'umutsi wa femoral (impuzandengo ya 6.4), hagakurikiraho imbere (impuzandengo ya 4.9) (Ishusho ya 2). Iyi mitsi ya trophoblastic yatangwaga ahanini n'imitsi ya geniculate imanuka (DGA) cyangwa umutsi wa geniculate (SMGA), ari na wo mu ishami ry'imitsi ya femoral iri hejuru, ikaba inatanga amashami y'imitsi, imitsi, cyangwa imitsi ya saphenous. DGA yaturutse ku mutsi wa femoral uri hejuru y'umutsi wegereye igice cy'imbere cya malleolus, cyangwa ku ntera ya cm 13.7 hafi y'ubuso bw'imitsi (cm 10.5-17.5), kandi amashami yari 89% mu bice by'umubiri (Ishusho ya 3). DGA ikomoka ku mutsi wo hejuru w’ubwonko ufite uburebure bwa cm 13.7 (cm 10.5-17.5) hafi y’agace k’umuyoboro wa malleolus cyangwa hafi y’ubuso bw’ingingo, hamwe n’ingero y’umurambo igaragaza amashami 100% ahamye n’umurambararo wa mm 0.78. Kubwibyo, DGA cyangwa SMGA birakwiye, nubwo iya mbere ikwiriye tibiae kubera uburebure n’umurambararo w’umutsi.
Ishusho ya 2. Ikwirakwizwa rya kane ry'imitsi ya trophoblast ya MFC ku murongo utambitse hagati ya semitendinosus na ligament ya medial collateral A, umurongo wa trochanter B nini, umurongo wa pole ya patella C, umurongo wa meniscus D y'imbere.
Ishusho ya 3. Imiterere y'imitsi ya MFC: (A) Amashami adasanzwe n'imiterere y'imitsi ya MFC trophoblastic, (B) Intera y'aho imitsi ikomoka uvuye ku murongo w'ingingo
Uburyo bwo kubaga
Umurwayi ashyirwa munsi y’ikinya rusange aryamye mu ntebe ye yo kuryama, amaguru yafashwe agashyirwa ku meza yo kubagwa ukuboko. Muri rusange, agapfundikizo k’igufwa gakurwa mu gice cy’imbere cy’ivi, kugira ngo umurwayi abashe kugenda akoresheje inkoni nyuma yo kubagwa. Ivi ryo ku ruhande rw’ivi rishobora kandi gutorwa iyo hari amateka y’ibyago cyangwa kubagwa byabanje ku ruhande rumwe rw’ivi. Ivi rirapfundikirwa kandi ikibuno gihindurirwa inyuma, kandi tourniquets zishyirwa ku mpande zombi zo hejuru n’izo hasi. Uburyo bwo kubaga bwari uburyo bwa Russe bwagutse, aho gukata guhera kuri cm 8 hafi y’umuyoboro wa carpal unyura hejuru kandi ukagera kure uvuye ku nkombe ya radial y’umuyoboro wa radial flexor carpi radialis, hanyuma ukagenda wizingira ku muyoboro wa carpal unyura hejuru werekeza ku gice cyo hasi cy’igikumwe, ukarangira ku rwego rwa trochanter nini. Agace k'imitsi y'uruti rw'umugongo rwa radial longissimus karacibwamo ibice maze uruti rugakururwa mu buryo burambuye, maze igufwa rya navicular rigashyirwa ahagaragara binyuze mu gukatagura gukomeye ku mitsi y'umutwe wa radial lunate na radial navicular, hagatandukanywa neza ibice byoroshye by'igufwa rya navicular kugira ngo igufwa rya navicular rikomeze kugaragara (Ishusho ya 4). Emeza ahantu hatabariwe, ubwiza bwa cartilage y'ingingo n'urugero rwa ishaza ry'igufwa rya navicular. Nyuma yo gukurura tourniquet, reba inkingi ya hafi y'igufwa rya navicular kugira ngo umenye niba hari ishaza ry'umugongo. Niba ishaza ry'umugongo ridafite aho rihuriye na radial carpal cyangwa intercarpal arthritis, MFC VGB ishobora gukoreshwa.
Ishusho ya 4. Uburyo bwo kubaga imitsi yo mu maguru: (A) Gukata gitangirira kuri cm 8 hafi y'umuyoboro wa carpal unyura hejuru kandi bikageza ku nkombe ya radial y'umutsi wa radial flexor carpi radialis kugeza ku gice cya kure cy'umutsi, ugatembera ahagana hasi ku gikumwe ku muyoboro wa carpal unyura hejuru. (B) Agace k'imitsi y'umutsi wa radial longissimus karacibwamo maze umutsi ukururwa mu mpande, maze igufwa rya navicular rigaragara binyuze mu gukatagura gukomeye ku mitsi y'umutwe wa radial lunate na radial navicular. (C) Garagaza agace k'aho imitsi yo mu maguru ihagarara.
Hakorwa icyuho cya cm 15-20 cy'uburebure hafi y'umurongo w'ivi ku mupaka w'inyuma w'imitsi yo hagati y'ijosi, maze imitsi igasubizwa inyuma kugira ngo amaraso ya MFC agaragare (Ishusho ya 5). Amaraso ya MFC muri rusange atangwa n'amashami ya DGA na SMGA, akenshi agafata ishami rinini rya DGA n'umutsi ujyana nayo. Umutsi wo mu mitsi urekurwa hafi, witaye ku kurinda periosteum n'imitsi ya trophoblastic ku buso bw'amagufwa.
Ishusho ya 5. Uburyo bwo kubaga MFC: (A) Hakozwe icyuho cya cm 15-20 hafi y'umupaka w'inyuma w'imitsi yo hagati y'ivi uhereye ku murongo w'ingingo z'ivi. (B) Imitsi isubizwa inyuma kugira ngo amaraso ya MFC agaragare.
Gutegura igufwa ryo mu jisho
Ubusembwa bwa DISI bwo mu mfuruka bugomba gukosorwa kandi agace k'agashishwa k'amagufwa ya osteochondral gategurwa mbere yo gushyirwamo hakoreshejwe fluoroscopy kugira ngo hasubizwe inguni isanzwe ya radial lunate (Ishusho ya 6). Agashishwa ka Kirschner ka metero 0.0625 (hafi mm 1.5) gatoborwa mu buryo bunyura hagati y'umugongo n'agashishwa ka metacarpal kugira ngo gashyireho urugingo rwa radial lunate, kandi icyuho cya navicular malunion kigaragara iyo ukuboko gutobotse. Ahantu ho kuvunika hakuwemo inyama zoroshye hanyuma hagafungurwa hakoreshejwe icyuma gitanga plate. Umukero muto usubirana ukoreshwa kugira ngo ugorore igufwa kandi urebe neza ko agashishwa ka implant kasa n'imiterere y'urukiramende kuruta agashishwa, bisaba ko icyuho cya navicular gifatwa n'icyuho kinini ku ruhande rw'ikiganza kuruta ku ruhande rw'umugongo. Nyuma yo gufungura icyuho, inenge ipimwa mu bipimo bitatu kugira ngo hamenyekane ingano ya graft y'amagufwa, ubusanzwe ifite uburebure bwa mm 10-12 ku mpande zose za graft.
Ishusho ya 6. Gukosora ubusembwa bw'umugongo w'inyuma, hakoreshejwe uburyo bwa fluoroscopic bwo guhindukira kw'ukuboko kugira ngo hagarurwe imiterere isanzwe ya radial-lunar. Agapira ka Kirschner gafite uburebure bwa metero 0.0625 (hafi mm 1.5) gatoborwa mu buryo bunyura hagati y'inyuma n'agapira ka metacarpal kugira ngo gafashe agace k'inyuma k'inyuma, gashyira ahagaragara icyuho cya navicular malunion kandi gasubize uburebure busanzwe bw'igufwa rya navicular iyo ukuboko kugororotse, ingano y'icyuho iteganya ingano y'ikibando kizakenera gufatwa.
Osteotomy
Agace gafite imitsi ya condyle y’imbere y’umugongo (medial femoral condyle) gatoranywa nk’agace gakuramo amagufwa, kandi agace gakuramo amagufwa karagaragazwa neza. Witondere kugira ngo udakomeretsa umugozi w’imbere w’umugongo. Periosteum iracibwa, hanyuma agace k’igufwa gafite uburebure bukwiye bw’agace gakenewe gacibwa n’icyuma gifata amagufwa, hagacibwa agace k’igufwa ka kabiri kuri 45° ku ruhande rumwe kugira ngo hamenyekane ko agace k’igufwa gahagaze neza (Ishusho ya 7). 7). Hagomba kwitonderwa ko hatavangurwa periosteum, igufwa rya cortical, n’igufwa rya cancellous ry’agace k’igufwa. Tourniquet yo hasi igomba kurekurwa kugira ngo hamenyekane uko amaraso atembera muri ako gasanduku, kandi umugongo w’imitsi ugomba kurekurwa hafi ya cm 6 kugira ngo habeho uburyo bwo kugabanya imitsi. Niba bibaye ngombwa, igufwa rito rya cancellous rishobora gukomeza muri femoral condyle. Ubusembwa bwa femoral condylar bwuzuzwa n’agace gasimbura igufwa, maze incision igakurwamo amazi kandi igafungwa urwego ku rundi.
Ishusho ya 7. Gukuraho ikiziba cy'amagufwa cya MFC. (A) Agace ko gutobora amagufwa gahagije kugira ngo kuzuza umwanya w'amagufwa yo mu mutwe karashyizweho ikimenyetso, igice cya periosteum kiracibwamo ibice, hanyuma ikiziba cy'amagufwa gifite uburebure bukwiye ku kiziba cyifuzwa kigacibwa n'icyuma gifatana. (B) Igice cya kabiri cy'igufwa gicibwa ku ruhande rumwe kuri 45° kugira ngo ikiziba cy'amagufwa gikomeze kuba cyiza.
Gutera no gufunga uruhu rw'imbere
Agace k'igufwa gashyirwa ku ishusho ikwiye, witonda kudakandagira umuyoboro w'amaraso cyangwa gukuraho igice cy'imbere. Agace k'igufwa gashyirwa buhoro buhoro mu gace k'igufwa ryangiritse, birinda gukomereka, kandi gashyirwamo utugozi tw'igufwa dupfutse. Hakozwe ubushakashatsi kugira ngo harebwe ko igice cy'igufwa cyashyizwemo gihuye n'igice cy'igufwa ryangiritse cyangwa ko cyagabanutseho gato kugira ngo hirindwe ko cyangirika. Hakozwe fluoroscopy kugira ngo hemezwe imiterere y'amagufwa yangiritse, umurongo w'imbaraga n'aho screw iherereye. Shyira umuyoboro w'amaraso yangiritse ku mpera y'umuyoboro w'amaraso ku ruhande rumwe n'umutwe w'amaraso ku mpera y'umuyoboro w'amaraso wangiritse ku rundi ruhande (Ishusho ya 8). Agapfukamunwa k'ingingo karasana, ariko igice cy'amaraso yangiritse kikirindwa.
Ishusho ya 8. Guteranya imitsi y'amagufwa, kuyishyiraho, no kuyigabanyamo imitsi y'amaraso. Umutsi w'amagufwa ushyirwa buhoro buhoro mu gace k'igufwa ry'amagufwa rikozwe mu buryo bworoshye kandi ugashyirwamo utugozi tw'amagufwa cyangwa udupira twa Kirschner. Hagomba kwitonderwa ko igice cya metacarpal cy'igufwa ryashyizwemo gihuzwa n'igice cya metacarpal cy'igufwa ry'amagufwa cyangwa kigashyirwamo gato kugira ngo hirindwe ko ritafatwa. Guteranya imitsi y'amaraso y'amagufwa ku mutsi w'amagufwa byakozwe mu mpera imwe ku yindi, naho igice cya nyuma cy'imitsi kijya ku mutsi w'amagufwa w'amagufwa cyakozwe mu mpera imwe ku yindi.
Gusubira mu buzima nyuma yo kubagwa
Aspirine inyobwa 325 mg ku munsi (ukwezi kumwe), nyuma yo kubagwa, guhagarara kw'ikirenge cyafashwe n'indwara biremewe, gufunga amavi bishobora kugabanya ububabare bw'umurwayi, bitewe n'ubushobozi bw'umurwayi bwo kugenda mu gihe gikwiye. Gushyigikira inkingi imwe y'ivi bishobora kugabanya ububabare, ariko gushyigikira inkingi z'ivi mu gihe kirekire si ngombwa. Imiti yakuweho ibyumweru 2 nyuma yo kubagwa kandi Muenster cyangwa inkingi ndende y'ukuboko kuva ku gikumwe iguma mu mwanya wayo mu gihe cy'ibyumweru 3. Nyuma y'ibyo, hakoreshwa inkingi ngufi y'ukuboko kuva ku gikumwe kugeza igihe imvune ikize. Imirasire ya X-ray ifatwa mu byumweru 3-6, kandi imvune ikira byemezwa na CT. Nyuma yaho, ibikorwa byo guhindukira no kongera imbaraga bigomba gutangira buhoro buhoro, kandi imbaraga n'inshuro by'imyitozo ngororamubiri bigomba kongerwa buhoro buhoro.
Ingorane zikomeye
Ingorane nyamukuru z’ingingo y’ivi zirimo kubabara mu ivi cyangwa gukomereka k’imitsi. Ububabare bw’ivi bwabaye mu byumweru 6 nyuma yo kubagwa, kandi nta gutakaza ibyiyumvo cyangwa neuroma ibabaza bitewe n’imvune ya saphenous byagaragaye. Ingorane nyamukuru z’ukuboko zari zirimo kudahuza kw’amagufwa, ububabare, gukomera kw’ingingo, intege nke, osteoarthritis ikomeza kwiyongera mu kuboko kwa radial cyangwa amagufwa ari hagati y’imitsi, ndetse n’ibyago byo kurema ibice by’umubiri bya heterotopic nabyo byaragaragaye.
Guteranya amagufwa yo mu bwoko bwa Medial Femoral Condyle Vascularized Grafting ku buntu kuri Scaphoid Nonunions hamwe na Proximal Pole Avascular Necrosis na Carpal Collapse
Igihe cyo kohereza: Gicurasi-28-2024
