Kwv yees li ntawm 5-15% ntawm tag nrho cov pob txha navicular tawg, nrog rau kwv yees li 3% ntawm cov pob txha navicular necrosis tshwm sim. Cov yam ua rau muaj navicular malunion suav nrog kev kuaj mob tsis tau lossis qeeb, qhov ze ntawm txoj kab tawg, qhov hloov pauv ntau dua 1 hli, thiab pob txha tawg nrog kev tsis ruaj khov ntawm carpal. Yog tias tsis kho, navicular osteochondral nonunion feem ntau cuam tshuam nrog kev mob pob qij txha, tseem hu ua navicular osteochondral nonunion nrog kev tawg osteoarthritis.
Kev siv pob txha txuas nrog lossis tsis muaj vascularised flap siv tau los kho navicular osteochondral nonunion. Txawm li cas los xij, rau cov neeg mob uas muaj osteonecrosis ntawm proximal pole ntawm pob txha navicular, cov txiaj ntsig ntawm kev txuas pob txha tsis muaj vascular tip tsis zoo, thiab tus nqi kho pob txha tsuas yog 40% -67%. Qhov sib piv, tus nqi kho ntawm cov pob txha txuas nrog vascularised flaps tuaj yeem siab txog 88% -91%. Cov vascularised pob txha tseem ceeb hauv kev kho mob suav nrog 1,2-ICSRA-tipped distal radius flap, bone graft + vascular bundle implant, palmar radius flap, free iliac bone flap nrog vascularised tip, thiab medial femoral condylar bone flap (MFC VBG), thiab lwm yam. Cov txiaj ntsig ntawm kev txuas pob txha nrog vascularised tip yog qhov zoo. Dawb MFC VBG tau pom tias muaj txiaj ntsig zoo hauv kev kho cov pob txha tawg navicular nrog metacarpal collapse, thiab MFC VBG siv ceg articular ntawm cov hlab ntsha hauv caug nqis ua ceg trophic tseem ceeb. Piv nrog rau lwm cov flaps, MFC VBG muab kev txhawb nqa txaus los kho cov qauv ntawm cov pob txha navicular, tshwj xeeb tshaj yog nyob rau hauv navicular fracture osteochondrosis nrog bowed back deformity (Daim Duab 1). Hauv kev kho mob ntawm navicular osteochondral osteonecrosis nrog kev tawg carpal zuj zus, 1,2-ICSRA-tipped distal radius flap tau tshaj tawm tias muaj tus nqi kho pob txha ntawm tsuas yog 40%, thaum MFC VBG muaj tus nqi kho pob txha ntawm 100%.
Daim Duab 1. Qhov pob txha navicular tawg nrog qhov "bowed back" deformity, CT qhia qhov pob txha tawg ntawm cov pob txha navicular ntawm lub kaum sab xis li ntawm 90°.
Kev npaj ua ntej phais
Tom qab kuaj xyuas lub dab teg uas raug mob, yuav tsum tau ua cov kev tshawb fawb txog kev siv duab los ntsuas seb lub dab teg puas tawg. Cov duab xoo hluav taws xob yooj yim muaj txiaj ntsig zoo los paub meej qhov chaw ntawm qhov tawg, qhov kev hloov pauv, thiab qhov muaj resorption lossis sclerosis ntawm qhov kawg tawg. Cov duab pem hauv ntej tom qab siv los ntsuas seb lub dab teg puas tawg, dorsal instability ntawm lub dab teg (DISI) siv qhov sib piv qhov siab ntawm lub dab teg hloov kho (qhov siab/dav) ntawm ≤1.52 lossis lub kaum sab xis radial lunate ntau dua 15°. MRI lossis CT tuaj yeem pab kuaj mob malalignment ntawm pob txha navicular lossis osteonecrosis. Cov duab xoo hluav taws xob sab nraud lossis oblique sagittal CT ntawm pob txha navicular nrog lub kaum sab xis navicular >45° qhia txog kev luv ntawm pob txha navicular, uas hu ua "bowed back deformity". MRI T1, T2 lub teeb liab qis qhia txog necrosis ntawm pob txha navicular, tab sis MRI tsis muaj qhov tseem ceeb hauv kev txiav txim siab qhov kho ntawm qhov tawg.
Cov cim qhia thiab contraindications:
Cov pob txha navicular osteochondral nonunion nrog rau qhov khoov rov qab thiab DISI; MRI qhia txog ischemic necrosis ntawm cov pob txha navicular, kev xoob ntawm lub tourniquet thaum lub sijhawm phais thiab kev soj ntsuam ntawm qhov tawg ntawm cov pob txha navicular tseem yog pob txha dawb sclerotic; qhov tsis ua tiav ntawm thawj qhov kev sib txuas pob txha wedge lossis ntsia hlau sab hauv yuav tsum tau muaj VGB structural bone grafting loj (> 1cm3). kev tshawb pom ua ntej lossis thaum lub sijhawm phais ntawm osteoarthritis ntawm radial carpal joint; yog tias muaj cov kab mob navicular malunion tseem ceeb nrog rau kev sib tsoo osteoarthritis, ces yuav tsum tau ua kom lub dab teg puas, navicular osteotomy, quadrangular fusion, proximal carpal osteotomy, tag nrho carpal fusion, thiab lwm yam, yuav tsum tau ua; navicular malunion, proximal necrosis, tab sis nrog cov pob txha navicular morphology ib txwm muaj (piv txwv li, non-displaced navicular fracture nrog cov ntshav tsis zoo rau proximal pole); kev luv ntawm navicular malunion yam tsis muaj osteonecrosis. (1,2-ICSRA tuaj yeem siv los hloov rau distal radius flap).
Kev Siv Anatomy
MFC VBG tau muab los ntawm ntau cov hlab ntsha me me interosseous trophoblastic (nruab nrab 30, 20-50), nrog rau cov ntshav ntau tshaj plaws nyob rau sab nraub qaum qis dua ntawm medial femoral condyle (nruab nrab 6.4), ua raws li anteriorly superior (nruab nrab 4.9) (Daim Duab 2). Cov hlab ntsha trophoblastic no feem ntau tau muab los ntawm cov hlab ntsha descending geniculate (DGA) thiab/lossis cov hlab ntsha superior medial geniculate (SMGA), uas yog ib ceg ntawm cov hlab ntsha superficial femoral uas kuj ua rau muaj cov ceg ntawm articular, musculocutaneous, thiab/lossis saphenous nerve. DGA tau pib los ntawm cov hlab ntsha superficial femoral proximal mus rau medial eminence ntawm medial malleolus, lossis ntawm qhov deb ntawm 13.7 cm proximal rau qhov chaw ntawm cov pob txha (10.5-17.5 cm), thiab qhov ruaj khov ntawm cov ceg yog 89% hauv cov qauv cadaveric (Daim Duab 3). Tus DGA pib los ntawm cov hlab ntsha superficial femoral ntawm 13.7 cm (10.5 cm-17.5 cm) proximal rau qhov medial malleolus fissure lossis proximal rau qhov articular surface, nrog rau cov qauv cadaveric qhia 100% branching stability thiab lub cheeb ntawm kwv yees li 0.78 mm. Yog li ntawd, DGA lossis SMGA yog qhov txais tau, txawm hais tias tus thawj zaug yog qhov tsim nyog dua rau tibiae vim qhov ntev thiab lub cheeb ntawm cov hlab ntsha.
Daim Duab 2. Kev faib plaub-quadrant ntawm MFC trophoblast cov hlab ntsha raws txoj kab kab rov tav ntawm semitendinosus thiab medial collateral ligament A, txoj kab ntawm lub trochanter loj dua B, txoj kab ntawm lub superior pole ntawm patella C, txoj kab ntawm anterior meniscus D.
Daim Duab 3. MFC cov hlab ntsha anatomy: (A) Cov ceg ntoo sab nraud thiab MFC trophoblastic vascular anatomy, (B) Qhov deb ntawm cov hlab ntsha keeb kwm los ntawm kab sib koom ua ke
Kev nkag mus rau hauv kev phais mob
Tus neeg mob raug tso rau hauv qab tshuaj loog dav dav hauv txoj haujlwm pw, nrog rau ceg uas raug mob tso rau ntawm lub rooj phais tes. Feem ntau, daim tawv nqaij ntawm tus neeg pub dawb raug coj los ntawm ipsilateral medial femoral condyle, yog li tus neeg mob tuaj yeem txav mus los nrog crutches tom qab phais. Lub hauv caug contralateral kuj tseem tuaj yeem xaiv yog tias muaj keeb kwm ntawm kev raug mob yav dhau los lossis phais rau tib sab ntawm lub hauv caug. Lub hauv caug raug flexed thiab lub duav raug tig sab nraud, thiab tourniquets raug siv rau ob qho tib si sab saud thiab sab qis. Txoj kev phais yog txoj hauv kev Russe ntev, nrog rau qhov phais pib 8 cm proximal rau transverse carpal tunnel thiab txuas ntxiv distally los ntawm radial ntug ntawm radial flexor carpi radialis tendon, thiab tom qab ntawd folding ntawm transverse carpal tunnel mus rau hauv paus ntawm tus ntiv tes xoo, xaus rau ntawm qib ntawm lub trochanter loj dua. Lub sheath ntawm cov leeg radial longissimus raug txiav thiab cov leeg raug rub tawm ulnarly, thiab cov pob txha navicular raug nthuav tawm los ntawm kev txiav ntse raws li radial lunate thiab radial navicular head ligaments, nrog kev sib cais ntawm cov ntaub so ntswg ntawm cov pob txha navicular kom tso cai rau kev nthuav tawm ntxiv ntawm cov pob txha navicular (Daim Duab 4). Paub meej tias thaj chaw ntawm nonunion, qhov zoo ntawm cov pob txha mos thiab qib ntawm ischaemia ntawm cov pob txha navicular. Tom qab loosened lub tourniquet, saib xyuas proximal pole ntawm cov pob txha navicular rau punctate bleeding los txiav txim siab seb puas muaj ischaemic necrosis. Yog tias navicular necrosis tsis cuam tshuam nrog radial carpal lossis intercarpal mob caj dab, MFC VGB yuav siv tau.
Daim Duab 4. Txoj kev phais mob Navicular: (A) Qhov kev phais pib 8 cm proximal rau ntawm transverse carpal tunnel thiab txuas ntxiv ntug radial ntawm radial flexor carpi radialis tendon mus rau qhov distal ntawm qhov kev phais, uas yog folded mus rau lub hauv paus ntawm tus ntiv tes xoo ntawm transverse carpal tunnel. (B) Lub tendon sheath ntawm radial longissimus tendon raug incised thiab cov tendon raug rub ulnarly, thiab cov pob txha navicular raug nthuav tawm los ntawm kev txiav ntse raws li radial lunate thiab radial navicular head ligaments. (C) Txheeb xyuas thaj chaw ntawm navicular osseous discontinuity.
Yuav muaj ib qho kev txiav ntev li 15-20 cm uas nyob ze rau ntawm txoj kab sib koom ua ke ntawm lub hauv caug raws ntug tom qab ntawm cov leeg nqaij medial femoral, thiab cov leeg nqaij raug rub rov qab rau pem hauv ntej kom pom cov ntshav MFC (Daim Duab 5). Cov ntshav MFC feem ntau yog muab los ntawm cov ceg sib koom ua ke ntawm DGA thiab SMGA, feem ntau yog siv ceg sib koom ua ke loj dua ntawm DGA thiab cov leeg ntshav uas sib koom ua ke. Cov hlab ntsha pedicle raug tso tawm ze rau ntawm cov leeg, ua tib zoo tiv thaiv cov periosteum thiab cov hlab ntsha trophoblastic ntawm qhov chaw pob txha.
Daim Duab 5. Kev nkag mus rau hauv MFC los ntawm kev phais: (A) Ib qho kev phais ntev 15-20 cm raug ua ze ntawm ciam teb tom qab ntawm cov leeg nqaij femoral medial los ntawm kab pob qij txha hauv caug. (B) Cov leeg nqaij raug rub rov qab rau pem hauv ntej kom pom cov ntshav MFC.
Kev npaj ntawm pob txha navicular
Yuav tsum kho qhov kev puas tsuaj ntawm navicular DISI thiab npaj thaj chaw ntawm pob txha osteochondral ua ntej cog los ntawm kev khoov lub dab teg hauv qab fluoroscopy kom rov qab tau lub kaum sab xis radial lunate ib txwm muaj (Daim Duab 6). Ib lub koob Kirschner 0.0625-foot (kwv yees li 1.5-mm) raug tho percutaneously los ntawm dorsal mus rau metacarpal los kho lub pob qij txha radial lunate, thiab qhov sib txawv navicular malunion raug nthuav tawm thaum lub dab teg ncaj. Qhov chaw tawg tau raug tshem tawm ntawm cov nqaij mos thiab ntxiv propped qhib nrog lub phaj spreader. Ib lub tshuab me me reciprocating siv los ua kom pob txha tiaj tus thiab xyuas kom meej tias lub implant flap zoo li lub qauv rectangular dua li lub wedge, uas yuav tsum tau ua kom qhov sib txawv navicular raug kov nrog qhov sib txawv dav dua ntawm sab palmar dua li ntawm sab dorsal. Tom qab qhib qhov sib txawv, qhov tsis zoo raug ntsuas hauv peb qhov ntev los txiav txim siab qhov dav ntawm pob txha graft, uas feem ntau yog 10-12 hli ntev ntawm txhua sab ntawm graft.
Daim Duab 6. Kho qhov khoov ntawm lub pob txha navicular, nrog rau kev khoov fluoroscopic ntawm lub dab teg kom rov qab tau qhov sib npaug radial-lunar li qub. Ib lub koob Kirschner 0.0625-foot (kwv yees li 1.5-mm) raug tho percutaneously los ntawm dorsal mus rau metacarpal los kho lub pob qij txha radial lunate, qhia txog qhov sib txawv navicular malunion thiab rov qab tau qhov siab li qub ntawm pob txha navicular thaum lub dab teg ncaj, nrog rau qhov loj ntawm qhov sib txawv kwv yees qhov loj ntawm daim tawv nqaij uas yuav tsum tau intercepted.
Kev phais pob txha
Thaj chaw vascularized ntawm medial femoral condyle raug xaiv ua thaj chaw ntawm kev rho tawm pob txha, thiab thaj chaw ntawm kev rho tawm pob txha tau cim txaus. Ceev faj tsis txhob ua rau lub medial collateral ligament raug mob. Lub periosteum raug txiav, thiab lub pob txha rectangular ntawm qhov loj me tsim nyog rau lub flap xav tau raug txiav nrog lub tshuab txiav rov qab, nrog rau lub pob txha thib ob txiav ntawm 45 ° raws ib sab kom ntseeg tau tias qhov kev ncaj ncees ntawm lub flap (Daim duab 7). 7). Yuav tsum ceev faj tsis txhob cais lub periosteum, pob txha cortical, thiab pob txha cancellous ntawm lub flap. Lub tourniquet qis dua yuav tsum tau tso tawm kom pom cov ntshav ntws los ntawm lub flap, thiab lub vascular pedicle yuav tsum tau tso tawm proximally rau tsawg kawg 6 cm kom tso cai rau cov vascular anastomosis tom qab. Yog tias tsim nyog, me me ntawm pob txha cancellous tuaj yeem txuas ntxiv mus rau hauv lub femoral condyle. Lub femoral condylar defect yog puv nrog cov pob txha graft hloov, thiab qhov incision yog drained thiab kaw txheej los ntawm txheej.
Daim Duab 7. Tshem tawm daim tawv pob txha MFC. (A) Thaj chaw osteotomy txaus kom puv qhov chaw navicular tau cim, periosteum raug txiav, thiab daim tawv pob txha plaub fab ntawm qhov loj me tsim nyog rau daim tawv pob txha xav tau raug txiav nrog lub tshuab txiav rov qab. (B) Ib daim pob txha thib ob raug txiav raws ib sab ntawm 45° kom ntseeg tau tias daim tawv pob txha ruaj khov.
Kev kho thiab fixation ntawm lub qhov ntswg
Lub pob txha daim tawv raug txiav kom zoo, ceev faj tsis txhob nias lub vascular pedicle lossis rhuav lub periosteum. Lub tawv raug cog maj mam rau hauv thaj chaw ntawm pob txha navicular, zam kev cuam tshuam, thiab kho nrog cov ntsia hlau navicular hollow. Tau ua tib zoo xyuas kom meej tias palmar margin ntawm cov pob txha uas cog rau hauv yog sib npaug nrog palmar margin ntawm pob txha navicular lossis nws tau nias me ntsis kom tsis txhob cuam tshuam. Tau ua fluoroscopy los xyuas kom meej cov pob txha navicular morphology, kab ntawm lub zog thiab qhov chaw ntsia hlau. Anastomose lub vascular flap artery mus rau radial artery kawg mus rau sab thiab lub venous tip mus rau radial artery companion vein kawg mus rau kawg (Daim Duab 8). Lub pob qij txha raug kho, tab sis vascular pedicle raug zam.
Daim Duab 8. Kev cog pob txha, kev kho, thiab kev sib txuas ntawm cov hlab ntsha. Lub pob txha raug muab tso rau hauv thaj chaw ntawm qhov tsis zoo ntawm pob txha navicular thiab kho nrog cov ntsia hlau navicular hollow lossis Kirschner pins. Yuav tsum ceev faj kom qhov metacarpal margin ntawm cov pob txha uas tau cog rau hauv yog sib npaug nrog metacarpal margin ntawm pob txha navicular lossis nias me ntsis kom tsis txhob sib tsoo. Kev sib txuas ntawm cov hlab ntsha flap artery mus rau radial artery tau ua tiav txij thaum kawg mus txog thaum kawg, thiab qhov kawg ntawm cov leeg mus rau radial artery companion vein tau ua tiav txij thaum kawg mus txog thaum kawg.
Kev kho dua tshiab tom qab phais
Noj tshuaj aspirin 325 mg ib hnub (rau 1 lub hlis), tom qab phais mob, tso cai rau kev nqa qhov hnyav ntawm ceg uas raug mob, kev nias lub hauv caug tuaj yeem txo qhov tsis xis nyob ntawm tus neeg mob, nyob ntawm tus neeg mob lub peev xwm txav mus los thaum lub sijhawm raug. Kev txhawb nqa ntawm ib tug pas nrig ntawm sab nraud tuaj yeem txo qhov mob, tab sis kev txhawb nqa ntev ntawm pas nrig tsis tas yuav tsum muaj. Cov xov tau raug tshem tawm 2 lub lis piam tom qab phais mob thiab Muenster lossis cov hlau nplaum ntev tes rau tus ntiv tes xoo tau khaws cia rau 3 lub lis piam. Tom qab ntawd, siv cov hlau nplaum luv tes rau tus ntiv tes xoo kom txog thaum qhov pob txha tawg zoo. X-rays raug thaij txhua 3-6 lub lis piam, thiab kev kho pob txha tawg tau lees paub los ntawm CT. Tom qab ntawd, kev ua ub no flexing thiab extension yuav tsum pib maj mam thiab tsis siv zog, thiab qhov hnyav thiab zaus ntawm kev tawm dag zog yuav tsum nce maj mam.
Cov teeb meem loj
Cov teeb meem tseem ceeb ntawm cov pob qij txha suav nrog mob hauv caug lossis raug mob ntawm cov hlab ntsha. Feem ntau mob hauv caug tshwm sim hauv 6 lub lis piam tom qab phais, thiab tsis pom muaj kev poob ntawm kev hnov lus lossis mob neuroma vim yog kev raug mob ntawm cov hlab ntsha saphenous. Cov teeb meem tseem ceeb ntawm dab teg suav nrog cov pob txha tsis sib koom ua ke, mob, pob qij txha tawv, tsis muaj zog, osteoarthritis ntawm lub dab teg radial lossis cov pob txha intercarpal zuj zus, thiab kev pheej hmoo ntawm periosteal heterotopic ossification kuj tau tshaj tawm.
Kev Siv Pob Txha Medial Femoral Condyle Vascularised Dawb Rau Scaphoid Nonunions Nrog Proximal Pole Avascular Necrosis Thiab Carpal Collapse
Lub sijhawm tshaj tawm: Tsib Hlis-28-2024
