Navicular malunion tshwm sim nyob rau hauv kwv yees li 5-15% ntawm tag nrho cov mob pob txha navicular, nrog navicular necrosis tshwm sim nyob rau hauv kwv yees li 3%. Cov xwm txheej txaus ntshai rau kev ua tsis zoo ntawm cov hlab ntsha muaj xws li kev kuaj tsis tau lossis ncua sijhawm, qhov sib thooj ntawm txoj kab tawg, kev hloov pauv ntau dua 1 hli, thiab tawg nrog carpal instability. Yog tias tsis kho, navicular osteochondral nonunion feem ntau cuam tshuam nrog kev mob caj dab, tseem hu ua navicular osteochondral nonunion nrog osteoarthritis.
Pob txha grafting nrog lossis tsis muaj vascularised nrov plig plawg tuaj yeem siv los kho navicular osteochondral nonunion. Txawm li cas los xij, rau cov neeg mob osteonecrosis ntawm tus ncej ntawm cov pob txha navicular, cov txiaj ntsig ntawm cov pob txha grafting tsis muaj vascular taub yog qhov tsis txaus siab, thiab cov pob txha kho tus nqi tsuas yog 40% -67%. Hauv qhov sib piv, qhov kho tus nqi ntawm cov pob txha grafts nrog vascularised flaps tuaj yeem siab li 88% -91%. Cov pob txha loj vascularised flaps hauv kev kho mob suav nrog 1,2-ICSRA-tipped distal radius flap, pob txha graft + vascular bundle implant, palmar radius flap, dawb iliac pob txha flap nrog vascularised tip, thiab medial femoral condylar pob txha nrov nrov (MFC VBG), thiab lwm yam. Cov txiaj ntsig ntawm pob txha grafting nrog vascularised taub yog txaus siab. Qhov dawb MFC VBG tau pom tias muaj txiaj ntsig zoo hauv kev kho mob ntawm cov pob txha navicular nrog metacarpal vau, thiab MFC VBG siv cov ceg ntoo ntawm cov hlab ntsha hauv lub hauv caug los ua lub ntsiab trophic. Piv nrog rau lwm cov flaps, MFC VBG muab kev txhawb nqa txaus kom rov qab zoo li qub ntawm cov pob txha navicular, tshwj xeeb tshaj yog nyob rau hauv cov pob txha navicular osteochondrosis nrog bowed back deformity (Daim duab 1). Nyob rau hauv kev kho mob ntawm navicular osteochondral osteonecrosis nrog kev loj hlob ntawm carpal vau, 1,2-ICSRA-tipped distal radius nrov plig plawg tau tshaj tawm tias muaj pob txha kho tus nqi tsuas yog 40%, thaum MFC VBG muaj cov pob txha kho ntawm 100%.
Daim duab 1. Fracture ntawm cov pob txha navicular nrog ib tug "bowed back" deformity, CT qhia cov pob txha tawg ntawm cov pob txha navicular ntawm lub kaum sab xis ntawm kwv yees li 90 °.
Kev npaj ua ntej
Tom qab kuaj xyuas lub cev ntawm lub dab teg cuam tshuam, kev tshawb fawb yuav tsum tau ua los ntsuas qhov ntsuas ntawm lub dab teg. Cov duab xoo hluav taws xob muaj txiaj ntsig zoo kom paub meej qhov chaw ntawm pob txha, qhov kev hloov pauv, thiab muaj cov resorption lossis sclerosis ntawm qhov kawg tawg. Posterior anterior dluab yog siv los ntsuam xyuas lub dab teg vau, dorsal instability ntawm lub dab teg (DISI) siv ib tug hloov dab teg qhov siab piv (qhov siab / dav) ntawm ≤1.52 los yog ib tug radial lunate lub kaum sab xis ntawm ntau dua 15 °. MRI lossis CT tuaj yeem pab txheeb xyuas qhov tsis zoo ntawm cov pob txha navicular lossis osteonecrosis. Lateral radiographs lossis oblique sagittal CT ntawm cov pob txha navicular nrog lub kaum sab xis navicular> 45 ° qhia kom luv ntawm cov pob txha navicular, uas yog hu ua " bowed back deformity". tsis muaj qhov pom tseeb qhov tseem ceeb hauv kev txiav txim siab kho cov pob txha.
Indications thiab contraindications:
Navicular osteochondral nonunion nrog bowed rov qab deformity thiab DISI; MRI qhia tau hais tias ischemic necrosis ntawm cov pob txha navicular, intraoperative loosening ntawm lub tourniquet thiab kev soj ntsuam ntawm cov pob txha tawg kawg ntawm cov pob txha navicular yog tseem dawb sclerotic pob txha; qhov tsis ua tiav ntawm qhov pib pob txha pob txha grafting lossis ntsia hlau sab hauv yuav tsum muaj VGB loj cov pob txha grafting (＞ 1cm3). preoperative lossis intraoperative tshawb pom ntawm osteoarthritis ntawm radial carpal sib koom; Yog tias qhov tseem ceeb ntawm kev ua tsis taus pa nrog kev sib tsoo osteoarthritis tau tshwm sim, tom qab ntawd lub dab teg denervation, navicular osteotomy, quadrangular fusion, proximal carpal osteotomy, tag nrho carpal fusion, thiab lwm yam, yuav tsum tau; navicular malunion, proximal necrosis, tab sis nrog ib txwm navicular pob txha morphology (piv txwv li, tsis muaj chaw nres nkoj navicular tawg nrog cov ntshav tsis zoo rau tus ncej ncej); shortening ntawm navicular malunion yam tsis muaj osteonecrosis. (1,2-ICSRA tuaj yeem siv los ua ib qho kev hloov pauv rau lub voj voos distal).
Applied Anatomy
MFC VBG yog muab los ntawm ib tug xov tooj ntawm me me interosseous trophoblastic hlab ntsha (txhais tau tias 30, 20-50), nrog rau cov ntshav ntau tshaj yog posteriorly inferior mus rau lub medial femoral condyle (txhais tau tias 6.4), ua raws li anteriorly superior (txhais tau tias 4.9) ( Daim duab 2). Cov hlab ntsha trophoblastic no tau muab los ntawm cov hlab ntsha qis qis (DGA) thiab / lossis cov hlab ntsha zoo tshaj plaws hauv nruab nrab geniculate artery (SMGA), uas yog ib ceg ntawm cov hlab ntsha femoral uas tseem ua rau cov hlab ntsha, musculocutaneous, thiab / lossis cov hlab ntsha saphenous. . DGA pib los ntawm cov hlab ntsha ntawm lub femoral artery proximal mus rau qhov nruab nrab eminence ntawm medial malleolus, los yog nyob deb ntawm 13.7 cm proximal mus rau articular nto (10.5-17.5 cm), thiab stability ntawm branching yog 89% nyob rau hauv cov qauv cadaveric. (Daim duab 3). Lub DGA pib los ntawm cov hlab ntsha ntawm lub femoral ntawm 13.7 cm (10.5 cm-17.5 cm) nyob ze rau ntawm qhov nruab nrab malleolus fissure los yog proximal mus rau articular nto, nrog ib tug cadaveric specimen qhia 100% branching stability thiab ib txoj kab uas hla ntawm kwv yees li 0.78 mm. Yog li ntawd, tog twg los DGA lossis SMGA tau txais, txawm hais tias yav dhau los yog tsim nyog rau tibiae vim qhov ntev thiab txoj kab uas hla ntawm lub nkoj.
Fig. 2. Plaub-quadrant faib ntawm MFC trophoblast cov hlab ntsha raws kab kab rov tav ntawm semitendinosus thiab medial collateral ligament A, kab ntawm ntau dua trochanter B, kab ntawm tus ncej superior ntawm patella C, kab ntawm lub anterior meniscus D.
Daim duab 3. MFC vascular anatomy: (A) Extraosseous ceg thiab MFC trophoblastic vascular anatomy, (B) Qhov deb ntawm vascular keeb kwm los ntawm cov kab sib txuas
Kev phais mob
Tus neeg mob tau muab tso rau hauv cov tshuaj loog nyob rau hauv txoj hauj lwm supine, nrog rau cov ceg uas cuam tshuam rau ntawm lub rooj phais tes. Feem ntau, tus pub pob txha nrov plig plawg yog muab los ntawm ipsilateral medial femoral condyle, kom tus neeg mob tuaj yeem txav tau nrog cov ntoo khaub lig tom qab kev phais. Lub hauv caug contralateral tuaj yeem xaiv tau yog tias muaj keeb kwm ntawm kev raug mob yav dhau los lossis kev phais ntawm tib sab ntawm lub hauv caug. Lub hauv caug yog flexed thiab lub duav yog sab nraud tig, thiab tourniquets yog siv rau ob qho tib si sab sauv thiab sab qis. Txoj kev phais yog qhov txuas ntxiv Russe mus kom ze, nrog rau qhov incision pib 8 cm ze rau lub transverse carpal qhov thiab ncua deb ntawm lub radial ntug ntawm lub radial flexor carpi radialis leeg, thiab ces folding ntawm transverse carpal qhov ntawm lub hauv paus ntawm tus ntiv tes xoo. , xaus ntawm qib ntawm trochanter ntau dua. Cov leeg nqaij ntawm radial longissimus tendon yog incised thiab cov leeg yog rub tawm ulnarly, thiab cov pob txha navicular raug nthuav tawm los ntawm kev sib tsoo ntse raws cov radial lunate thiab radial navicular taub hau ligaments, nrog ceev faj sib cais ntawm cov nqaij mos peripheral ntawm cov pob txha navicular kom tso cai. txuas ntxiv ntawm cov pob txha navicular (Daim duab 4). Paub meej tias thaj tsam ntawm nonunion, qhov zoo ntawm cov pob txha pob txha thiab qhov degree ntawm ischemia ntawm cov pob txha navicular. Tom qab loosening lub tourniquet, saib tus ncej ntawm cov pob txha navicular rau punctate los ntshav los txiav txim seb puas muaj ischemic necrosis. Yog hais tias tus navicular necrosis tsis cuam tshuam nrog radial carpal lossis intercarpal mob caj dab, MFC VGB tuaj yeem siv.
Daim duab 4. Navicular phais txoj hauv kev: (A) Qhov kev phais pib 8 cm nyob ze rau ntawm qhov transverse carpal qhov thiab txuas mus rau sab ntug ntawm lub radial flexor carpi radialis tendon mus rau qhov distal ntawm qhov incision, uas yog folded ntawm lub hauv paus ntawm tus ntiv tes xoo. nyob rau hauv lub transverse carpal qhov. (B) Cov leeg nqaij ntawm radial longissimus tendon yog incised thiab cov leeg yog rub tawm ulnarly, thiab cov pob txha navicular raug nthuav tawm los ntawm kev txiav ntse ntse raws li radial lunate thiab radial navicular taub hau ligaments. (C) Txheeb xyuas thaj tsam ntawm qhov tsis sib xws ntawm navicular osseous.
Ib qho kev txiav ntev 15-20 cm yog ua rau ze rau ntawm lub hauv caug sib koom kab raws li tus ciam teb tom qab ntawm cov leeg nqaij nruab nrab, thiab cov leeg tau thim rov qab los ua kom pom cov ntshav MFC (Fig. 5).MFC cov ntshav yog feem ntau muab. los ntawm cov ceg ntoo ntawm DGA thiab SMGA, feem ntau noj cov ceg sib koom ua ke loj dua ntawm DGA thiab cov hlab ntsha sib txuas. Lub vascular pedicle yog tso tawm proximally, saib xyuas los tiv thaiv periosteum thiab cov hlab ntsha trophoblastic ntawm pob txha.
Daim duab 5. Kev phais kev nkag mus rau MFC: (A) Ib txoj kab ntev 15-20 cm yog ua nyob ze ntawm ciam teb tom qab ntawm cov leeg nqaij nruab nrab ntawm lub hauv caug kab. (B) Cov leeg tau thim rov qab los nthuav tawm MFC cov ntshav..
Kev npaj ntawm cov pob txha navicular
Lub navicular DISI deformity yuav tsum tau kho thiab thaj tsam ntawm cov pob txha osteochondral graft npaj ua ntej cog los ntawm flexing lub dab teg nyob rau hauv fluoroscopy los kho ib tug radial lunate lub kaum sab xis (Daim duab 6). Ib tug 0.0625-ko taw (kwv yees li 1.5-mm) Kirschner tus pin yog drilled percutaneously los ntawm dorsal mus rau metacarpal fixate lub radial lunate sib koom, thiab qhov sib txawv navicular malunion raug nthuav tawm thaum lub dab teg ncaj. Qhov chaw tawg tau raug tshem tawm ntawm cov ntaub so ntswg thiab ntxiv propped qhib nrog lub phaj spreader. Ib tug me me reciprocating saw yog siv los flatten cov pob txha thiab xyuas kom meej tias lub implant nrov plig plawg zoo li ntau dua ntawm ib lub voj voog ntau tshaj li ib tug wedge, uas yuav tsum tau hais tias qhov sib txawv navicular yuav tsum tau nrog ib tug dav qhov sib txawv ntawm lub palmar sab tshaj nyob rau hauv lub dorsal sab. Tom qab qhib qhov sib txawv, qhov tsis xws luag yog ntsuas nyob rau hauv peb qhov ntev los txiav txim seb qhov twg ntawm cov pob txha graft, uas feem ntau yog 10-12 mm ntev ntawm txhua sab ntawm graft.
Daim duab 6. Kho ntawm lub bowed rov qab deformity ntawm lub navicular, nrog fluoroscopic flexion ntawm lub dab teg kom rov zoo li qub radial-lunar alignment. Ib tug 0.0625-ko taw (kwv yees li 1.5-mm) Kirschner tus pin yog drilled percutaneously los ntawm dorsal mus rau metacarpal fixate lub radial lunate sib koom, nthuav tawm qhov sib txawv navicular malunion thiab kho qhov siab ntawm cov pob txha navicular thaum lub dab teg ncaj, nrog qhov loj ntawm qhov sib txawv kwv yees qhov loj ntawm lub flap uas yuav tsum tau cuam tshuam.
Osteotomy
Lub vascularised cheeb tsam ntawm medial femoral condyle raug xaiv raws li thaj tsam ntawm cov pob txha rho tawm, thiab thaj tsam ntawm cov pob txha rho tawm yog cim txaus. Ceev faj kom tsis txhob raug mob ntawm qhov nruab nrab collateral ligament. Lub periosteum yog incised, thiab cov pob txha pob txha ntawm qhov tsim nyog loj rau qhov xav tau nrov plig plawg yog txiav nrog ib tug reciprocating saw, nrog ib tug thib ob pob txha thaiv txiav ntawm 45 ° nyob rau ib sab kom ntseeg tau tias lub meej mom ntawm lub flap (Fig. 7). 7). Kev saib xyuas yuav tsum tsis txhob cais cov periosteum, pob txha cortical, thiab cov pob txha tshem tawm ntawm lub flap. Qhov qis kawg ntawm qhov tourniquet yuav tsum tau tso tawm kom pom cov ntshav ntws los ntawm lub ntsej muag, thiab lub vascular pedicle yuav tsum tau tso tawm ze li ntawm 6 cm kom tso cai rau vascular anastomosis tom ntej. Yog tias tsim nyog, ib qho me me ntawm cov pob txha tshem tawm tuaj yeem txuas ntxiv mus rau hauv femoral condyle. Lub femoral condylar defect yog sau nrog cov pob txha graft hloov, thiab qhov incision yog drained thiab kaw txheej los ntawm txheej.
Daim duab 7. MFC pob txha flap tshem tawm. (A) Lub cheeb tsam osteotomy txaus los sau qhov chaw navicular yog cim, lub periosteum yog incised, thiab cov pob txha pob txha ntawm qhov tsim nyog loj rau qhov xav tau nrov plig plawg yog txiav nrog ib tug reciprocating saw. (B) Ib daim thib ob ntawm cov pob txha raug txiav nrog ib sab ntawm 45 ° kom ntseeg tau tias kev ncaj ncees ntawm lub flap.
Flap implantation thiab fixation
Cov pob txha nrov plig plawg yog txiav mus rau qhov tsim nyog, saib xyuas kom tsis txhob ntim cov hlab ntsha pedicle lossis strip lub periosteum. Lub flap yog maj mam implanted rau hauv thaj tsam ntawm cov pob txha navicular tsis xws luag, tsis txhob percussion, thiab tsau nrog hollow navicular screws. Kev saib xyuas kom ntseeg tau tias lub paj paj ntawm cov pob txha implanted tau ntws nrog cov paj ntoo ntawm cov pob txha navicular los yog tias nws muaj kev ntxhov siab me ntsis kom tsis txhob cuam tshuam. Fluoroscopy tau ua kom paub tseeb tias cov pob txha navicular morphology, kab ntawm quab yuam thiab ntsia hlau txoj hauj lwm. Anastomose vascular flap artery mus rau radial artery kawg mus rau sab thiab cov venous tip mus rau radial artery companion vein kawg (Daim duab 8). Kev sib koom ua ke tshuaj ntsiav yog kho, tab sis lub vascular pedicle raug zam.
Daim duab 8. Pob txha flap implantation, fixation, thiab vascular anastomosis. Cov pob txha nrov plig plawg yog maj mam muab cog rau hauv thaj tsam ntawm cov pob txha navicular thiab kho nrog hollow navicular screws lossis Kirschner pins. Kev saib xyuas yog coj mus rau qhov metacarpal npoo ntawm cov pob txha implanted yog flush nrog cov metacarpal margin ntawm cov pob txha navicular los yog me ntsis kev nyuaj siab kom tsis txhob cuam tshuam. Anastomosis ntawm vascular flap artery mus rau radial artery tau ua tiav kawg nkaus, thiab cov hlab ntsha mus rau radial artery khub leeg leeg tau ua tiav kawg.
Postoperative rehabilitation
Qhov ncauj tshuaj aspirin 325 mg ib hnub twg (rau 1 lub hlis), postoperative weight- bearing of the cuam tshuam limb raug tso cai, hauv caug braking tuaj yeem txo qhov tsis xis nyob ntawm tus neeg mob, nyob ntawm tus neeg mob lub peev xwm txav tau raws sijhawm. Kev txhawb nqa tsis sib haum ntawm ib tus ntoo khaub lig tuaj yeem txo qhov mob, tab sis kev txhawb nqa ntev ntawm cov ntoo ntoo tsis tsim nyog. Cov stitches raug tshem tawm 2 lub lis piam tom qab kev phais thiab Muenster los yog caj npab ntev rau tus ntiv tes xoo tau muab tso rau hauv qhov chaw rau 3 lub lis piam. Tom qab ntawd, lub caj npab luv mus rau ntiv tes xoo yog siv kom txog thaum lub pob txha zoo. X-rays raug coj los ntawm 3-6 lub lis piam ib ntus, thiab kev kho pob txha raug lees paub los ntawm CT. Tom qab ntawd, active thiab passive flexion thiab ncua kev ua ub no yuav tsum tau pib maj mam, thiab kev siv zog thiab zaus ntawm kev tawm dag zog yuav tsum tau nce zuj zus.
Cov teeb meem loj
Cov teeb meem tseem ceeb ntawm lub hauv caug pob qij txha muaj xws li mob hauv caug lossis mob paj hlwb. Qhov mob hauv caug feem ntau tshwm sim nyob rau hauv 6 lub lis piam tom qab kev phais, thiab tsis muaj qhov tsis hnov tsw lossis mob neuroma vim qhov raug mob saphenous paj. Cov teeb meem hauv dab teg tseem ceeb suav nrog cov pob txha refractory nonunion, mob, sib koom ua ke nruj, tsis muaj zog, kev mob osteoarthritis ntawm radial dab teg lossis cov pob txha intercarpal, thiab kev pheej hmoo ntawm periosteal heterotopic ossification kuj tau tshaj tawm.
Dawb Medial Femoral Condyle Vascularised Pob txha Grafting rau Scaphoid Nonunions nrog Proximal Ncej Avascular Necrosis thiab Carpal Collapse
Post lub sij hawm: May-28-2024
