Marvsømning Generelle principper · 2018-08-20 · excellent tibial alignment, union, knee ROM,...
Transcript of Marvsømning Generelle principper · 2018-08-20 · excellent tibial alignment, union, knee ROM,...
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Marvsømning – Generelle principper
Specialespecifikt kursus i traumatologi, Århus 2015 Anders Jordy
Overlæge Traumesektoren Ortopædkir. Afd. Kolding Sygehus
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Dette foredrag kommer ind på følgende…
1. Indikation for anvendelse af marvsøm
2. Marvsømsbiomekanik!
3. Reaming
4. Indføring af marvsømning
5. Låsning
6. Særlig udfordringer
Anders Jordy, Kolding Sygehus
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1. Indikationer for brug af marvsøm
Anders Jordy, Kolding Sygehus
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2. Biomekanik – marvsømmets egenskaber
Anders Jordy, Kolding Sygehus
• ”Stang i rør” – Genskaber axial alignment
• Rotation og længde – Låseskruer - muligheder
• Modvirke deformation – Bøjning og torsion
• Fleksibilitet – Solid – hult - slidset
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2. Biomekanik - Grundbegreber
Anders Jordy, Kolding Sygehus
• Antallet af failures (non-unioun, late-union, loss of reduction, implant failures) er betinget af osteosyntesens stivhed
• Stivheden i en osteosyntese er betinget af: 1. Sømmets diameter
2. Sømmets længde
3. Gripping strenght
A. Ruiz et al, Injury, vol 31,2000
Drosos et al, JBJ (Br), vol 88 B, 2006
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• Stivheden er proportional med radius i fjerde (r4)
• Dvs. hvis man vælger et marvsøm på 10 mm i stedet for 9 mm. , bliver stivheden øget med ca. 45%
2.1 Biomekanik - sømdiameter
Anders Jordy, Kolding Sygehus
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2.2 Biomekanik – sømlængde
• Sømlængde
Anders Jordy, Kolding Sygehus
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2.2 Biomekanik - sømlængde
Anders Jordy, Kolding Sygehus
• Sømlængde
• Arbejdslængde (AL)
– Det u-understøttede område af sømmet
– Omvendt proportionalt med AL i anden (1/AL
2)
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• Friktionen mellem søm og knogle
– Nedsætter arbejdslængden og øger dermed stivheden
• Øges ved
– Større diameter
– Mindre overreaming
– Tværskruer • (tilstrækkeligt antal, vinkelrette, statiske, vinkelstabile?)
2.3 Biomekanik – gripping strength
Anders Jordy, Kolding Sygehus
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2. Biomekanik – ergo…
• Få failures er afhængig af osteosyntesens stivhed
• Osteosyntesens stivhed er afhængig af
– Gripping strength
– Som opnås ved
• Langt marvsøm
• Kort arbejdslængde
• Stor sømdiameter
• Pressfit (minimal overreaming)
Anders Jordy, Kolding Sygehus
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Anders Jordy, Kolding Sygehus
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3. Reaming
Anders Jordy, Kolding Sygehus
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3. Reaming – skal udføres med omtanke
1. Frakturen er reponeret korrekt (akser)
2. Guidewiren er placeret rigtigt. (CENTRALT I 2 PLAN)
3. Kun knoglen skal reames – ikke bløddelene
4. Altid start med 8,5 mm(andet skærehoved)
5. Ream kun lige forbi isthmus/fraktur
6. Over-ream kun 1mm (1,5mm) til og med isthmus
7. Udvis forsigtighed ved komminutte frakturer
Anders Jordy, Kolding Sygehus
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3. Reaming – komminut fraktur
Anders Jordy, Kolding Sygehus
UHA
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3. Reaming
Fordele • Tillader større søm
diameter
• Bedre søm/knoglekontakt, øget stabilitet
• Reamersmulder stimulerer osteogenese
• Nedsat risiko for iatrogen fraktur ved indføring af sømmet
Ulemper • Ødelægger primære
blodforsyning(heling?)
• Overreaming kan øge risiko for malalignment
• Knoglenekrose pga. øget temp.(husk ingen blodtomhed)
• Ved femur-reamning og samtidig thorax-traume kan der ses en øget risiko for lungekomplikationer
Anders Jordy, Kolding Sygehus
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4. Indføring – entry point
Anders Jordy, Kolding Sygehus
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4. Indføring – entry point
Anders Jordy, Kolding Sygehus
• Vigtigt for resten af operationens fremdrift
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4. Entry point femur
Anders Jordy, Kolding Sygehus
Lateral trochanterich
Retrograde adgang via knæleddet.
Originale Küntcher adgang Fossa piriformis
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Lige søm
Let kurvet søm
Mere kurveret søm
Anders Jordy, Kolding Sygehus
4. Entry point - femur
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Lige søm
Anders Jordy, Kolding Sygehus
4. Entry point - femur
Let kurvet søm
Mere kurveret søm
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Tornetta et al. J Orthop Trauma 13(4), 1999. Safe zone: 9+5 mm lat for midtline tibial plateau og 3 mm lat
for centrum tub tibia.
Anders Jordy, Kolding Sygehus
Hernigou & Cohen. J Bone Joint Surg Br. 2000 Jan;82(1):33-41. Proximal entry for intramedullary nailing of the tibia. The risk of unrecognised articular damage. Safe zone: ant for lig transversum og begge meniskers forhorn.
4. Entry point tibia – hvad er bedst
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Anders Jordy, Kolding Sygehus
J Trauma. 2008 Jun;64 Toivanen,J CONCLUSION: Compared with a transpatellar tendon approach, a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment after intramedullary nailing of a tibial shaft fracture. In long term, anterior knee pain seems to disappear from many patients.
4. Entry point tibia – ligament patella
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4. Indføring
Anders Jordy, Kolding Sygehus
x Ø = 2X
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5. låsning
• Rækkefølgen på låsning
– Sikre rotation
– Kompression/længde
• Guidet låsning
• Runde huller/svensker metoden
• ASLS
Anders Jordy, Kolding Sygehus
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6. Særlige udfordringer
• Metafysære frakturer
• Adipositas
Anders Jordy, Kolding Sygehus
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Anders Jordy, Kolding Sygehus
6. Særlige udfordringer
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Anders Jordy, Kolding Sygehus
”Our 1-year results indicate that the procedure resulted in excellent tibial alignment, union, knee ROM, with no apparent sequelae in the PF joint based on immediate arthroscopy and 1-year MRI scans.”
“Even more interesting was the absence of anterior tibialpain typically found in up to 25%–60% of cases where a tibial nail is inserted in a standard fashion.”
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Huskat, vigtigt, take home mm.!
• Marvsøm skal være lange og tykke
• Marvsøm skal sidde godt fast (gripping strength)
– Derfor er det nødvendigt at daske dem i.
• Ream altid, men tænk dig om
• Entry point, entry point – entry point
• Rigelig med låse skruer
Anders Jordy, Kolding Sygehus
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Spørgsmål?
Anders Jordy, Kolding Sygehus