【作者】 殷浩；

【导师】 孙俊英；

【作者基本信息】 苏州大学 ， 骨外科学， 2008， 博士

【摘要】 第一部分正常髋关节股骨偏心距的影像学研究目的测量研究正常国人股骨偏心距的大小并探讨其临床意义,为国人股骨假体设计及临床应用提供依据。方法对100例正常双髋关节X线片进行影像学测量,测量参数包括股骨偏心距、颈干角、股骨头直径、外展肌力臂、体重力臂、小转子中点及其上下20mm的冠状径、峡部直径和髓腔闪烁指数等,统计学分析股骨偏心距与外展肌力臂、体重力臂、股骨髓腔各解剖参数的相关关系及男女各参数间的差异,并将测量结果与国内外学者的测量参数进行比较。结果正常国人股骨偏心距大小为36.64±5.31mm,总体均数的95%可信区间为35.59~37.69 mm,其中男性股骨偏心距大小为38.58±5.66mm,总体均数的95%CI为36. 97~40.19 mm,女性股骨偏心距大小为34.71±4.18mm,总体均数的95%CI为33. 52~35.90 mm;股骨偏心距与外展肌力臂呈明显的正相关(r=0.73, P<0.01),与股骨颈干角呈负相关(r=-0.46, P<0.01),与股骨头直径呈正相关(r=0.35, P<0.05),与其它股骨近端解剖参数无明显相关性。国人男女两性间股骨偏心距、颈干角、股骨头直径、外展肌力臂有显著性差异(P<0.05)。国人股骨偏心距、颈干角与白种人有显著性差异(P<0.01)。结论正常国人股骨偏心距大小为36.64±5.31mm,总体均数的95%CI为35.59~37.69 mm。正常国人男女两性间及国人与白种人间股骨偏心距、颈干角有显著性差异。重建股骨偏心距有利于恢复外展肌力臂,维持髋关节的软组织平衡,重建正常髋关节生物力学。提供不同固定的颈干角或颈干角、偏心距可调的股骨假体有利于重建股骨偏心距。第二部分全髋关节置换前后股骨及假体应力的三维有限元分析目的建立正常人体完整股骨的三维有限元模型并探讨生物型全髋关节置换前后股骨及假体的应力变化及其临床意义;方法采用活体髋关节标本,应用CT扫描及逆向工程技术,建立正常人体完整股骨的三维有限元模型。观察在关节合力和相关肌肉载荷下,synergy股骨锥形柄假体置入前后股骨及假体的应力变化;结果成功构建了完整股骨的三维有限元模型,可以满足有限元分析的需要。正常股骨内外侧应力远大于前后侧,内侧受压应力,外侧受张应力,应力峰值位于股骨中上部;全髋置换后股骨应力的传导方式发生了改变,但没有改变正常股骨的应力模式,近端出现显著的应力遮挡,股骨应力峰值在置换后降低,假体末端股骨上的应力增加明显。股骨假体的应力模式方式与股骨基本一致,其头颈部是应力集中区。结论股骨偏心距是影响股骨应力传递的重要因素;股骨假体的置入改变了完整股骨的应力传导方式;股骨近端的应力遮挡和假体末端骨质的应力集中是股骨近端假体周围骨溶解和股前区疼痛的力学基础。第三部分两种股骨偏心距重建方法对股骨及假体的生物力学影响目的探讨加大股骨偏心距对全髋置换前后股骨和假体的生物力学影响及改变股骨假体颈长和使用高偏心距股骨假体两种重建股骨偏心距方法的差异;方法利用完整股骨的三维有限元模型,模拟全髋置换手术,观察在关节合力和相关肌肉载荷下,置入长颈股骨假体和高偏心距假体两种假体后对股骨及假体的应力、界面微动等生物力学影响并与标准颈股骨假体相比较;结果股骨假体偏心距的增加,对股骨应力的变化影响不明显,但增加了股骨假体颈部应力、近端界面间剪切应力和微动。使用长颈假体尤其明显,高偏心距假体相对长颈假体应力分布比较均匀,界面剪切应力和假体末端应力集中较少。结论增加股骨假体偏心距可导致假体颈部应力和近端界面微动增加;两种不同重建偏心距的方法对股骨应力影响的差异不明显;重建股骨偏心距应结合患者情况个性化实施;高偏心距假体是重建股骨偏心距的良好选择。第四部分股骨偏心距重建与全髋置换术后假体功能的临床研究目的探讨股骨偏心距重建(FO)与全髋置换术(THA)后假体功能的相关性及术中影响股骨偏心距重建的因素;方法对我科2002年3月至2007年7月间施行的THA进行随访,随访时间10~72个月,平均21.3个月,对随访资料完整的61例THA进行回顾性分析。其中男性31例,女性30例;年龄57.4±18.2岁(37~84岁)。左侧34例,右侧27例。手术均由同一位医师采用统一直接外侧入路进行。在手术前后双髋正位X线片上进行FO、外展肌力臂、股骨矩的长度、髋关节旋转中心位置及双下肢长度差的影像学测量。观察记录手术前后患者的步态、髋关节活动范围、外展肌力和Harris评分,并用SPSS统计软件对上述资料进行统计学分析。结果术后61例中44例( 72.1%)的FO得到了重建;简单相关分析显示,FO与股骨外展肌力臂正相关(r=0.673;P<0.001);FO与双下肢长度差存在正相关(r=0.47,P<0.05),两侧FO差值与两侧髋关节旋转中心的水平距离、垂直距离差值有相关关系(分别为r=-0.17,r=0.60 ,P<0.05);股骨假体的头颈长度与FO存在正相关(r=0.594, P< 0.05);股骨矩的保留长度与FO存在正相关(r=0.319, P< 0.05) ;FO与Harris评分正相关(r=0.47, P< 0.05); FO重建组的Harris评分、髋关节活动范围、外展肌力明显优于非重建组(p<0.01),而臀中肌步态、Trendelenburg(+)征、髋关节撞击征、骨溶解、脱位等并发症低于非重建组(p<0.05)。结论股骨偏心距重建与全髋置换术后的外展肌力、双下肢等长、关节活动范围、关节稳定性和步态等功能密切相关;术中影响股骨偏心距重建的因素有髋关节旋转中心位置、假体颈干角、假体颈长及股骨矩保留高度;全髋置换术中重建股骨偏心距应结合术前模板测量,选择接近解剖颈干角的股骨假体,通过调节假体头颈长,综合下肢的长度和软组织张力进行。更多还原

【Abstract】 PartⅠThe radiographic study of femoral offset in normal hip jointObjective: To investage the range of femoral offset in the healthy Chinese and explore its clinical significance.Methods 100 cases of normal anteroposterior hip joints radiographic image were measured. Parameters included femoral offset, abductor lever arm , femoral head diameter, neck-shaft angle, the width of bone medullary cavity at the plane of lesser trochanter,20mm above and below the lesser trochanter,diameter of the narrow cavity and canal flare index (CFI). The correlation between femoral offset and other anatomical parameters in femur were explored by simple correlation analysis.The proximal femoral parameters between Chinese and the Western were compared. Results The range of femoral offset was 36.64±5.31mm,and the 95% confidence interval (CI )overall mean was 35.59~37.69 mm in healthy Chinese. The range of femoral offset was 38.58±5.66mm and the 95% CI overall mean was 36.97~40.19 mm in Chinese man. The range of femoral offset was 34.71±4.18mm and the 95% CI overall mean was 33.52~35.90 mm in Chinese woman .Femoral offset and abductor lever arm was positively correlated(r=0.73, P<0.01).Femoral offset was negatively correlated neck-shaft angle(r=-0.46, P<0.01). Femoral offset was positively correlated with femoral head diameter(r=0.35, P<0.05).There were no significance correlation between femoral offset and other parameters of the femoral medullary canal. There was a significant difference in the diameter of the femoral head, neck-shaft angle, femoral offset, abductor lever arm between Chinese men and women (P <0.05). There was a significant difference in neck-shaft angle,femoral offset between Chinese and the Western (P <0.01).Conclusion The range of femoral offset was 36.64±5.31mm,and the 95% CI overall mean was 35.59~37.69 mm in healthy Chinese. There was a significant difference in neck-shaft angle, femoral offset between Chinese and the Western.Restoration of femoral offset can recovery the length of abductor lever arm and balance the soft tissue of the hip.Femur prosthesis with different neck stem angle or modular prosthesis are suitable to reconstruct normal hip joint biomechanics.PartⅡ3 D finite element analysis of stress changes of prosthesis and femur before and after total hip arthroplastyObjective: To establish a three-dimensional finite element model of intact normal femur and determine stress distribution of prosthesis and femur before and after total hip arthroplasty. Methods: A finite element models of an intact femur and a femoral prosthesis were established by normal hip joint in vivo CT scans and Mimics 10.0 software; then stress distribution analysis was carried out when both joint contact forces and muscle forces were included in the loading. Results: The peak stress of intact femur was presented at the middle and upper regions of femur with compressive stress in medial side and tensile stress in lateral side. The stress pattern of implanted femur was similar to the one of intact femur with the obvious stress shielding at proximal femur. The stress pattern of femoral prosthesis was similar to the one of intact femur with stress concentration in the site of the combination of head -neck.Conclusions: Implantation of femur prosthesis may cause significant stress shielding in the proximal femur and stress concentration at the end of stem. This may be related with periprosthetic bone loss and aseptic loosening of stem and can be used to explain the mechanism of postoperative thigh pain. PartⅢBiomechanics analysis of prosthesis and femur before and after total hip arthroplasty using two differerent methors of femoral offset restorationObjective: To explore the change of stress distribution of prosthesis and femur before and after total hip arthroplasty with a long neck stem or high offset stem. Methods: A finite element models of an intact femur and femoral prostheses were developed by computed simulation, then a simulation surgery of total hip arthroplasty were taken and femoral prosthesis with long neck stem or high offset stem were implanted respectively. The changes of biomechanics of prostheses and femur before and after total hip arthroplasty with a long neck stem or high offset stem were observed. Results: There was no significant change of the stress transfer and stress distribution with increased femoral offset. The interfacial shear stress and interfacial micromotion increased in the bone-prosthesis interaction.The stress increased with increased femoral offset in the neck of prosthesis becaused of large bend moment. It was the mechanical basis of the fatigue of prosthesis. High offset prosthesis more uniformed stress distribution and provided less concentrate stress. Conclusions: The interfacial stress and micromotion in the proximal femur would increase with an increased femoral offset prosthesis. There was no significient difference betweeen two different methods of femoral offset restoration on the effect on the stress distribution of femur.Construction Restoration of femoral offset should be taken individually. High offset prosthesis was a good choice to restore femoral offset in THA.PartⅣClinical research between femoral offset restoration and joint function after total hip arthroplastyObjective: To explore the correlation between femoral offset(FO)restoration and joint function after total hip arthroplasty(THA) and influence factors of femoral offset restoration in operation. Methods: 61 patients were performed THA from Mar 2002 to July 2007 and follow-up was finished. There were 30 women and 31 men and the average age was 57.4 years (37 to 84 yr).The right hip had been replaced in 34, the left in 27. The mean duration of clinical and roentgenographic follow-up was 21.3 months (10~72m). FO, abductor lever arm, residual length of femoral calcar, leg length discrepancy and location of hip rotation center were measured from each radiograph. Gait,range of motion of hip,hip abduction strength and hip harris score were recored. Statistical data was performed using SPSS 10.0 software. Results: FO of 44 hip( 71.9%)were restored in 61 THA. Simple correlation analysis showed that FO correlated with the length of the abductor lever arm (r=0.673,P<0.001);residual length of femoral calcar (r=0.319,P<0.05);leg length difference (r=0.47,P<0.05), hip harris score (r=0.47,P<0.05). The difference of FO on both sides was correlated with the difference of horizontal and vertical hip rotation location on both sides (r=-0.17,r=0.60). The harris score, range of motion of hip ,hip abduction strength in construction group were better than those of no construction group(P<0.01).The gluteus medius gait,Trendelenburg sign(+)and other complications were less than those of no construction group. Conclusions Restoration of FO significantly influenced the hip abductor strength,leg length discrepancy,gait,range of motion of hip and hip stability.The infulence factors of FO restoration include the location of the hip rotation center,neck length of prosthesis ,neck stem angle of prosthesis and residual length of femoral calcar. To restore femoral offset in THA,template the both side hip preoperatively,select femoral prosthesis with more anatomical neck-shaft angle,modular leg length and soft tissue tensile intraoperative were necessary.更多还原