【作者】 侯继光；

【导师】 张国川；

【作者基本信息】 河北医科大学 ， 外科学， 2010， 硕士

【摘要】 目的:股骨干骨折是骨科临床上最常见的骨折。闭合复位髓内钉技术是主要治疗方法。在闭合复位内固定术中如果旋转力线纠正不良常会引起创伤性关节炎等一系列临床症状,严重影响患者术后的日常生活。所以在闭合复位内固定术中对股骨旋转的判断尤为重要。临床上缺少判断股骨旋转力线的客观数据,在术中主要依靠术者的肉眼观测,根据经验做出判断,导致术后很多患者存在股骨旋转畸形。在解剖学上对不同旋转状态下的股骨形态研究亦较少。股骨大转子和小转子是股骨近端的显著性解剖标志。小转子因为形状较为规则,并伴随股骨旋转角度的变化,高度和宽度发生相应改变,已经较早的应用于估计、判断股骨的旋转状态。而大转子与股骨旋转状态的相关性还未做过相应的测量与研究。本实验通过对身体健康的20名志愿者拍摄双腿处于中立位、内旋5°、10°、15°、20°,外旋5°、10°、15°、20°的X线片,对股骨大转子处于不同旋转角度下形态发生的变化做出研究。并提出股骨大转子倾斜率的概念,记录下不同旋转角度下股骨大转子倾斜率的数值,分析、总结股骨大转子倾斜率与旋转角度之间的相关性。根据总结的股骨大转子倾斜率与旋转角度的规律判断股骨的旋转状态,指导股骨干骨折闭合复位手术中下肢旋转力线的纠正。方法: 20位身体健康的成年志愿者,男性10位、女性10位,年龄20-58岁,平均年龄39岁,平均身高167.13cm,平均体重68.94Kg。平躺于水平检查台上,双侧膝关节置于水平检查台边缘,双膝屈曲90°,膝关节远端垂直悬挂于水平检查台边缘,并使两股骨髁之间的直线距离与两股骨大转子之间的直线距离相等,以确保志愿者双下肢处于中立位,用铅衣保护非观察部位。旋转数字减影X线拍片机(DR)的球管发射器,使志愿者下肢处于相对旋转状态,例如球管发射器内旋5°时拍摄的是股骨外旋5°时的X线片。拍摄时按照先男性后女性,先右腿后左腿顺序完成,每个志愿者分别拍摄双腿处于中立位、内旋5°、10°、15°、20°,外旋5°、10°、15°、20°的X线片并在平片上做出标记。记录志愿者的性别、年龄、身高、体重。用SIENET Magicview 300测量软件测量出不同旋转角度下股骨大转子前嵴结节到转子间线的垂直距离、小转子下股骨干横径,所有数据由同一观测者测量,每个数据测量3遍,记录其平均数,然后计算出股骨大转子倾斜率。对同一角度下不同性别、不同肢体的股骨大转子倾斜率做统计学分析。对不同旋转角度下的股骨大转子倾斜率做统计学分析。对股骨旋转角度与股骨大转子倾斜率做统计学相关性分析。计算不同旋转角度下的股骨大转子倾斜的95%参考范围。以大转子倾斜率为指导对20名股骨干近端1/3患者进行闭合复位髓内钉术。术后从患者的手术时间、术中出血量、股骨旋转畸形情况、髋膝关节功能、骨折愈合时间等多方面进行评估。结果:在内旋20°到外旋20°范围内同一志愿者相同旋转角度下股骨大转子倾斜率左右腿之间无统计学意义(P>0.05),同一旋转角度不同性别之间无统计学意义(P>0.05)。同一志愿者旋转角度间隔5°的相邻两组股骨大转子倾斜率的变化有统计学意义(P<0.05),每外旋5°时的股骨大转子倾斜率的均数是逐步增大的。从内旋20°到外旋20°股骨大转子倾斜率平均数由0.18增大到0.47。内旋20°为0.18±0.06、内旋15°0.21±0.07、内旋10°0.25±0.07、内旋5°0.27±0.07,中立位0.30±0.08、外旋5°0.34±0.09、外旋10°0.38±0.09、外旋15°0.42±0.12、外旋20°0.47±0.12。不同旋转角度的95%参考范围:内旋20°为[0.06,0.3]、内旋15°[0.07,0.35]、内旋10°[0.11,0.39]、内旋5°[0.13,0.41],中立位[0.14,0.46],外旋5°[0.16,0.52]、外旋10°[0.20,0.56]外旋15°[0.28,0.66]、外旋20°[0.23,0.71]。股骨大转子倾斜率与外旋角度的变化成正直线相关,可以用直线回归方程:股骨大转子倾斜率=0.31+0.01*旋转角度(内旋为负,外旋为正。r=0.993 P<0.00001),旋转角度=-22.85+73.18*股骨大转子整体倾斜率(内旋为负,外旋为正,r=0.719 P<0.00001),表示股骨大转子倾斜率与旋转角度之间的相互关系。以股骨大转子倾斜率为指导进行闭合复位髓内钉术,手术操作平均时间1.2h、平均出血量150ml。股骨旋转畸形小于5°的4例,占总体的20%;小于10°的11例,占总体的55%;小于15°的3例,占总体的15%;小于20°的2例占总体的10%。髋关节功能Sanders评分,优18例,良2例。膝关节功能Hohl评分,优19例,良1例。骨折平均愈合时间4.2个月。结论:股骨大转子倾斜率在同一旋转角度下性别之间、左右腿之间无显著性差异。股骨大转子倾斜度在旋转角度变化5°有显著性差异。股骨大转子倾斜率在股骨外旋时增大,内旋时减小。从内旋20°到外旋20°股骨大转子倾斜率髓股骨外旋角度的增大而增大。不同旋转角度下95%参考范围重合区间较大不适合用来帮助判断旋转角度。可以根据直线回归方程:旋转角度=-22.85+73.18*股骨大转子整体倾斜率(内旋为负,外旋为正,r=0.719 P<0.00001)通过计算股骨大转子倾斜率来计算旋转角度,指导股骨干骨折旋转力线的纠正,并取得良好疗效。但要精确纠正股骨旋转应先拍摄健侧股骨近端中立位的正位X线片,计算股骨大转子倾斜率,指导患侧股骨旋转复位。更多还原

【Abstract】 Objective: Femoral shaft fracture is the most common orthopedic clinical fractures. Closed interlocked intramedullary nailing is the main treatment. In the closed reduction and internal fixation if the rotational malalignment is excessive , it often causes traumatic arthritis with a series of clinical symptoms, severely affects the daily life of patients. Therefore, the judgment on the rotational malalignment during the closed locked intramedullary nailing of the femur is particularly important. Clinically,beause of the lack of objective data that judge the rotational malalignment of the femur, the operators depend mainly on visual observation in surgery and make judgments based on experience to minimize the occurance of rotational malalignment, resulting many patients in rotational deformity after the operation. The study on the different rotational states of the femur is less in the anatomy. Femoral greater trochanter and the lesser trochanter is the significance landmarks of proximal femoral anatomic. The lesser trochanter has earlier applied to judge the rotational alignment of the femur, beause of the rule shape and the corresponding changes that accompany by the femoral rotation. But the relevance between the corresponding change of the greater trochanter and the rotational state of femur is not measured and researched. Through this experiment, 20 healthy volunteers were taked the radiographs of proximal femurs in the following position : neutral position, 5°, 10°, 15°, 20°internal rotation, 5°, 10°, 15°, 20°external rotation . Then make a study of morphological changes of greater trochanter in different rotational angles, introduce this concept of“the tilt ratio of the greater trochanter”. Every radiograph is recorded the rates of greater trochanter tilt , and summarized the correlation between the tilt rates of the greater trochanter and rotational angle. According to the laws that between the tilt rates of the greater trochanter and rotational angle to judge the rotational malalignment to achieve optimum rotational alignment during the closed locked intramedullary nailing of the femur.Methods: 20 healthy adult volunteers, 10 men, 10 women, mean age of 39 years(range20-58), mean height of 167.13cm, the average weight of 68.94Kg. Lying at the level of inspection stage, to determine the neutral position of femur, the subject was supine with knee flexed at 90°and the lower leg hanging vertically down over the edge of examining table. The distance between the bilateral femoral condyles was equal to that between the bilateral proximal femurs at the greater trochanter level, with the protection clothing to protect non-observed parts of the volunteers. Rotate the tube launcher of the X ray film machine digital radiography (DR) , so the proximal femurs of the volunteers at a relatively rotational state, such as when the tube launcher of the X-ray films is 5°internal rotation , the radiograph is 5°external rotation of femoral. Taking the radiograph in turns with men first , right leg first, each volunteer were taken radiograph of proximal femurs at the following position: neutral position, 5°, 10°, 15°, 20°internal rotation, 5°, 10°, 15°, 20°external rotation and the radiographs were obtained by tilting of the radiographic system whose window could show the angle simultaneously, sex, age, height, weight of the volunteers. With the SIENET Magicview 300 measurement software to measure the vertical distance between the greater trochanteric anterior tubercle and intertrochanteric line, subtrochanteric femoral diameter at the different rotational angles, recorded the average value of all the data that measured three times by the same observer and then calculate the tilt rate of the greater trochanter. The change of the tilt rate of the greater trochanter different sexes, different limbs at the same rotational angle was did statistical analysis. The change of the tilt rate of the greater trochanter at different rotationl angles was did statistical analysis. Statistical correlation analysis was did between the femur rotational angles and the tilt rate of the greater trochanter. Calculated the 95% reference range of the the tilt rate of the greater trochanter at different rotational angles. By the radiological landmark of the tilt rate of the greater trochanter to judge femoral position so as to prevent rotational deformity , twenty patients of the proximal femoral shaft 1 / 3 were did closed locked intramedullary nailing of the femur. The results were evaluated from the patient’s operation time, blood loss, rotational deformity of the femur, hip and knee function, fracture healing time and other aspects.Results: From 20°internal rotatation to 20°external rotation at the same rotational angle of the same volunteers, the tilt rate of the greater trochanter was no statistical significance between the left leg and the right leg (P> 0.05), the same rotation angle was not statistical significance between the sexes (P> 0.05). The same volunteers, 5°rotation angle of adjacent two intervals the tilt rate of the greater trochanter changes was statistical significant (p <0.05), for every 5°external rotation when the tilt rate of the greater trochanter was gradually increasing . From 20°internal rotation to 20°external rotation , the average of the tilt rate of the greater trochanter increased from 0.18 to 0.47. The tilt rate of the greater trochanter when 20°internal rotation was 0.18±0.06, 15°internal rotation was 0.21±0.07, 10°internal rotation was 0.25±0.07, 5°internal rotation was 0.27±0.07, neutral position was 0.30±0.08, 5°external rotation was 0.34±0.09, 10°external rotation was 0.38±0.09, 15°external rotation was 0.42±0.12, 20°external rotation was 0.47±0.12. The 95% reference range of the tilt rate of the greater trochanter of different rotation angles: 20°internal rotation was [0.06,0.3], 15°internal rotation was [0.07,0.35], 10°internal rotation was [0.11,0.39], 5°internal rotation was [0.13,0.41], neutral position was [0.14,0.46], 5°external rotation was [0.16,0.52], 10°external rotation was [0.20,0.56] ,15°external rotation was [0.28,0.66], 20°external rotation was [0.23,0.71]. The relationship between the tilt rate of femoral greater trochanter and the external rotation angles was a positive linear correlation, we can use linear regression equation: the tilt rate of the greater trochanter = 0.31 +0.01 * rotation angle (internal rotation is negative, external rotation is positive. R = 0.993 P < 0.00001), rotational angle = -22.85 +73.18 * the tilt rate of the greater trochanter (internal rotation is negative, external rotation is positive, r = 0.719 P <0.00001) , indicating the relationship between the tilt rate of the greater trochanter and the rotational angles. When the tilt rate of the greater trochanter was as a technique to obtain the correct rotational alignment during closed interlocked intramedullary nailing, the operation average time was 1.2h, the average amount of bleeding was 150ml. Deformity of the femoral rotation was 4 cases less than 5°, accounting for 20% of the total; was 11 cases less than 10°, accounting for 55% of the total; was 3 cases less than 15°, accounting for 15% of the total; was 2 cases less than 20°,accounted for 10% of the total. The hip joint function of the Sanders score, 18 cases were excellent, 2 cases were good. The knee function of the Hohl score, 19 cases were excellent, 1 case were good. The healing time of fracture was 4.2 months on average.Conclusion: The tilt rate of greater trochanter in the same rotational angle between the sexes, left and right legs, was no significant difference. The change of the tilt rate of the greater trochanter when the rotation angle increasing 5°was a significant difference. The tilt rate of the greater trochanter increased when the femoral was external rotation, and decreased when internal rotation. From 20°internal rotation to 20°external rotation, the tilt rate of the greater trochanter increased as the angle of femoral external rotation increases. The 95% reference range of the tilt rate of the greater trochanter at different rotation angle is overlap, so it is not suitable to judge the rotational malalignment. Based on linear regression equation: rotational angle = -22.85 +73.18 * the tilt rate of the greater trochanter (internal rotation is negative, external rotation is positive, r = 0.719 P <0.00001) , calculate the tilt rate of the greater trochanter to judge the rotational malalignment so as to restore the rotation alignment of the femur shaft fracture, and achieved good effect. But to accurately restore the femoral rotational alignment should first take the anterior radiograph at neutral position of the contralateral proximal femur. Take the contralateral tilt rate of the greater trochanter to restore the femur rotational alignment.更多还原