本文關(guān)鍵詞： 股骨頭壞死 保髖治療 臨床療效 生物陶瓷 β-磷酸三鈣 有限元分析 股骨頭壞死 應(yīng)力 位移 載荷 步態(tài) β-磷酸三鈣 生物陶瓷　出處：《廣西醫(yī)科大學(xué)》2017年博士論文　論文類型：學(xué)位論文

【摘要】：第一部分β-磷酸三鈣生物陶瓷棒系統(tǒng)治療早期股骨頭壞死的臨床研究目的:觀察β-磷酸三鈣生物陶瓷棒系統(tǒng)植入術(shù)治療早期股骨頭壞死的短期臨床療效,探討術(shù)前因素(年齡、BMI指數(shù)、病程時(shí)間、病因、壞死范圍、骨髓水腫分級(jí)、術(shù)前髖關(guān)節(jié)Harris評(píng)分和術(shù)前髖關(guān)節(jié)疼痛VAS評(píng)分)對(duì)β-磷酸三鈣生物陶瓷棒植入術(shù)療效的影響。方法:對(duì)2015年4月到2015年8月收治的接受β-磷酸三鈣陶瓷棒系統(tǒng)植入手術(shù)治療的股骨頭壞死患者34例(35髖)進(jìn)行術(shù)后短期的觀察及隨訪。對(duì)術(shù)前、術(shù)后第6個(gè)月,術(shù)后第12個(gè)月,術(shù)后第18個(gè)月髖關(guān)節(jié)Harris評(píng)分、髖關(guān)節(jié)Harris評(píng)分優(yōu)良率及髖關(guān)節(jié)疼痛VAS評(píng)分進(jìn)行統(tǒng)計(jì)學(xué)分析。從術(shù)后第6個(gè)月,術(shù)后第12個(gè)月,術(shù)后第18個(gè)月進(jìn)行影像學(xué)的評(píng)價(jià)。分析術(shù)前年齡、BMI指數(shù)、病程時(shí)間、病因、壞死范圍、骨髓水腫分級(jí)、術(shù)前髖關(guān)節(jié)Harris評(píng)分及術(shù)前髖關(guān)節(jié)疼痛VAS評(píng)分與術(shù)后髖關(guān)節(jié)Harris評(píng)分及術(shù)后髖關(guān)節(jié)疼痛VAS評(píng)分的相關(guān)性。結(jié)果:所有患者均隨訪至術(shù)后18個(gè)月。(1)髖關(guān)節(jié)Harris評(píng)分結(jié)果術(shù)后各時(shí)間點(diǎn)的髖關(guān)節(jié)Harris評(píng)分均分別較術(shù)前髖關(guān)節(jié)Harris評(píng)分有明顯提高,差異具有統(tǒng)計(jì)學(xué)意義(P0.05);術(shù)后髖關(guān)節(jié)Harris評(píng)分優(yōu)良率明顯提高。(2)髖關(guān)節(jié)疼痛VSA評(píng)分的結(jié)果術(shù)后各時(shí)間點(diǎn)的髖關(guān)節(jié)疼痛VAS評(píng)分均分別較術(shù)前髖關(guān)節(jié)疼痛VAS評(píng)分有明顯降低,差異具有統(tǒng)計(jì)學(xué)意義(P0.05)(3)術(shù)前各因素與術(shù)前髖關(guān)節(jié)Harris評(píng)分的關(guān)系年齡、BMI指數(shù)、病程時(shí)間、病因、壞死范圍、骨髓水腫分級(jí)和術(shù)前髖關(guān)節(jié)疼痛VAS評(píng)分均與術(shù)前髖關(guān)節(jié)Harris評(píng)分無(wú)相關(guān)性(P0.05)。(4)術(shù)前各因素與術(shù)前髖關(guān)節(jié)疼痛VAS評(píng)分的關(guān)系骨髓水腫分級(jí)與術(shù)前髖關(guān)節(jié)疼痛VAS評(píng)分成正相關(guān)性(P0.05),其余因素?zé)o相關(guān)性(P0.05)。(5)術(shù)前各因素與術(shù)后髖關(guān)節(jié)Harris評(píng)分的關(guān)系年齡、BMI指數(shù)、病變范圍和術(shù)前髖關(guān)節(jié)Harris評(píng)分與術(shù)后髖關(guān)節(jié)Harris評(píng)分有相關(guān)性(P0.05),其余因素?zé)o相關(guān)性(P0.05)。(6)術(shù)前各因素與術(shù)后髖關(guān)節(jié)疼痛VAS評(píng)分的關(guān)系BMI指數(shù)和病變范圍與術(shù)后髖關(guān)節(jié)疼痛VAS評(píng)分有相關(guān)性(P0.05),其余因素?zé)o相關(guān)性(P0.05)。(7)影像學(xué)結(jié)果35髖按照ARCO分期進(jìn)行影像學(xué)評(píng)估,至術(shù)后6個(gè)月時(shí),穩(wěn)定24髖,穩(wěn)定率68.57%;至術(shù)后12個(gè)月時(shí),穩(wěn)定27髖,穩(wěn)定率77.14%;至術(shù)后18個(gè)月時(shí),穩(wěn)定31髖,穩(wěn)定率88.57%。3髖發(fā)生股骨頭塌陷,術(shù)后18個(gè)月時(shí)的保髖率為91.43%。結(jié)論:采用β-磷酸三鈣生物陶瓷棒系統(tǒng)植入術(shù)治療早期股骨頭壞死,可有效改善髖關(guān)節(jié)功能,緩解癥狀,阻止影像學(xué)進(jìn)展,獲得比較高的保髖率,近期療效滿意。在進(jìn)行臨床療效評(píng)估及手術(shù)適應(yīng)癥選擇時(shí),需要考慮年齡、BMI指數(shù)、病變范圍和術(shù)前髖關(guān)節(jié)Harris評(píng)分因素的影響。第二部分基于三維有限元分析的β-磷酸三鈣生物陶瓷棒系統(tǒng)治療早期股骨頭壞死的生物力學(xué)研究目的:應(yīng)用三維有限元方法,建立壞死股骨頭病灶及植入β-磷酸三鈣生物陶瓷棒系統(tǒng)后的股骨頭三維有限元模型,觀察β-磷酸三鈣生物陶瓷棒系統(tǒng)植入術(shù)對(duì)早期股骨頭壞死的生物力學(xué)影響,為β-磷酸三鈣生物陶瓷棒系統(tǒng)治療股骨頭壞死提供力學(xué)方面的理論依據(jù)。方法:利用CT對(duì)一名健康成年男性髖關(guān)節(jié)進(jìn)行薄層掃描,建立正常股骨近端有限元模型,在此基礎(chǔ)上建立壞死區(qū)域位于前外上側(cè)15%、后外上側(cè)15%、前外上側(cè)30%、后外上側(cè)30%與負(fù)重區(qū)塌陷2mm、負(fù)重區(qū)塌陷4mm的早期壞死股骨頭及模擬植入β-磷酸三鈣生物陶瓷棒系統(tǒng)后的股骨頭有限元模型,分別加載普通行走、慢速跑步、快速跑步三種力學(xué)載荷,觀察β-磷酸三鈣生物陶瓷棒系統(tǒng)治療前后股骨頭應(yīng)力及位移變化情況,并判斷不同步態(tài)下股骨頭塌陷的風(fēng)險(xiǎn)。結(jié)果:(1)在普通步行、慢速跑步、快速跑步三種載荷下,相比治療前,治療后股骨頭應(yīng)力集中現(xiàn)象有所改善,股骨頭應(yīng)力值與整體位移值,股骨頭負(fù)重區(qū)應(yīng)力值與塌陷值,壞死區(qū)應(yīng)力值與位移值較治療前減小,差異具有統(tǒng)計(jì)學(xué)意義(P0.05)。隨著載荷的增加,壞死股骨頭的應(yīng)力與整體位移值,股骨頭負(fù)重區(qū)應(yīng)力值與塌陷值,壞死區(qū)應(yīng)力值與位移值隨之增大。壞死范圍15%與30%位于前外上側(cè)與后外上側(cè),股骨頭應(yīng)力值與塌陷值,壞死區(qū)應(yīng)力值與位移值均無(wú)明顯差異(P0.05)。(2)根據(jù)塌陷準(zhǔn)則,在普通步行、慢速跑步、快速跑步下,術(shù)前與術(shù)后壞死范圍30%比壞死范圍15%的股骨頭塌陷風(fēng)險(xiǎn)大,塌陷4mm比塌陷2mm的股骨頭再次塌陷風(fēng)險(xiǎn)大,且隨著載荷的加大,塌陷風(fēng)險(xiǎn)增加。術(shù)后塌陷風(fēng)險(xiǎn)比術(shù)前塌陷風(fēng)險(xiǎn)有所降低,但隨著載荷的加大,塌陷風(fēng)險(xiǎn)增加。壞死范圍15%與30%位于前外上側(cè)與后外上側(cè),塌陷風(fēng)險(xiǎn)無(wú)太大差別。結(jié)論:(1)有限元分析模型能夠有效模擬β-磷酸三鈣生物陶瓷棒系統(tǒng)植入股骨頭壞死區(qū)域的生物力學(xué)變化。(2)β-磷酸三鈣生物陶瓷棒系統(tǒng)植入可有效改善壞死股骨頭內(nèi)部的力學(xué)性能,增加壞死股骨頭負(fù)重區(qū)骨的支撐能力,降低壞死區(qū)骨的壓應(yīng)力,減少壞死股骨頭塌陷的風(fēng)險(xiǎn)。(3)β-磷酸三鈣生物陶瓷棒系統(tǒng)的力學(xué)支撐能力有限,隨著載荷的增加,壞死股骨頭塌陷的風(fēng)險(xiǎn)逐漸增大。對(duì)于壞死范圍較小及塌陷程度輕的效果要好于壞死范圍較大及塌陷程度重的股骨頭壞死。(4)從生物力學(xué)角度進(jìn)行療效評(píng)價(jià),為β-磷酸三鈣陶瓷棒系統(tǒng)治療股骨頭壞死提供生物力學(xué)方面的理論依據(jù)。
[Abstract]:The first part is clinical study of tricalcium phosphate ceramic rod system in the treatment of early femoral head necrosis: short term clinical observation of tricalcium phosphate ceramic rod system implantation in the treatment of early avascular necrosis of the femoral head, to investigate the preoperative factors (age, BMI index, disease duration, etiology, necrosis, bone marrow edema grading, preoperative Harris hip score and preoperative hip pain VAS score) effect on tricalcium phosphate ceramic rod implantation. Methods: from April 2015 to August 2015 were treated with beta tricalcium phosphate ceramic rod system implanted into the surgical treatment of femoral head necrosis in 34 patients (35 hips) observation the short-term and follow-up after surgery. Preoperative, postoperative sixth months, twelfth months after the surgery, postoperative Harris hip score at eighteenth months, Harris hip score and excellent rate of hip joint pain VAS score was statistically analyzed. The postoperative Sixth months, twelfth months after the operation was evaluated eighteenth months after surgery. The imaging analysis of preoperative BMI index, age, disease duration, etiology, necrosis, bone marrow edema grading, preoperative Harris hip score and preoperative hip pain VAS score and postoperative Harris hip rating. And after hip joint pain VAS score. Results: all patients were followed up to 18 months after the operation. (1) hip Harris score after hip joint Harris each time point scores were compared with the preoperative Harris hip score increased significantly, the differences were statistically significant (P0.05); operation after the Harris hip score excellent rate increased. (2) hip pain VSA scores after hip joint pain VAS at different time points were respectively compared to the preoperative hip pain VAS score was significantly decreased, the difference was statistically significant (P0.05) (3) preoperative factors and preoperative hip The relationship between age, Harris score BMI index, disease duration, etiology, classification and operation scope of necrosis, bone marrow edema before hip pain VAS score and preoperative Harris hip score had no correlation (P0.05). (4) the relationship between preoperative grading of bone marrow edema and operation factors and preoperative VAS score of hip joint pain the hip joint pain VAS score was positively correlated (P0.05), there was no correlation between other factors (P0.05). (5) preoperative factors and postoperative Harris hip score between age, BMI index, lesion area and preoperative Harris hip score and postoperative Harris hip score correlation (P0.05), no correlation between other factors (P0.05). (6) preoperative factors and postoperative hip pain VAS score between BMI index and the extent of the lesion and postoperative hip pain VAS score correlation (P0.05), there was no correlation between other factors (P0.05). (7) the imaging results of 35 hips with ARCO Staging imaging assessment at 6 months after operation, stable in 24 hips, stable rate of 68.57%; and 12 months after operation, stable in 27 hips, stable rate of 77.14%; and 18 months after operation, stable in 31 hips, stable rate of 88.57%.3 hip femoral head collapse, hip preserving 18 months the rate of postoperative 91.43%. conclusion: using tricalcium phosphate ceramic rod system implantation in the treatment of early avascular necrosis of the femoral head, can effectively improve the hip joint function, relieve symptoms, prevent radiographic progression, get hip preserving high rate, the short-term curative effect is satisfactory. In clinical curative effect evaluation and surgical indications when the need to consider the age, BMI index, Harris score of hip joint lesion and preoperative factors. The second part is to study the biomechanical three dimensional finite element analysis of tricalcium phosphate ceramic rod system in the treatment of early avascular necrosis of the femoral head based on Application of 3D finite element method is established A three-dimensional finite element model of avascular necrosis of the femoral head lesions and implantation of tricalcium phosphate ceramic rod system, observe the biomechanical effects of tricalcium phosphate ceramic rod system implantation for early avascular necrosis of the femoral head, the theoretical basis for tricalcium phosphate ceramic rod system in the treatment of femoral head necrosis with mechanics.. method: TLC scanning of a healthy adult male hip by CT, the establishment of normal proximal femur finite element model is established on the basis of necrotic area located on the front side of the outer side outside the 15%, after 15%, before the upper 30%, after the upper 30% and weight-bearing area of collapse 2mm, 4mm early necrosis of femoral simulation of bone and implant tricalcium phosphate ceramic rod system finite element model of the femoral head after the weight-bearing area collapse, were loaded with common walking, slow running fast, running three kinds of mechanical load, observation of tricalcium phosphate The ceramic rod system in the treatment of femoral head before and after the change of stress and displacement, and determine the collapse of femoral head under different gait risk. Results: (1) in normal walking, slow running, fast running under three loads, compared with before treatment, the stress concentration phenomenon has been improved after the treatment of femoral bone, femoral head stress value with the overall displacement and stress value of the weight-bearing area of femoral head necrosis area and subsidence value, stress value and displacement value decreased than that before treatment, the difference was statistically significant (P0.05). With the increase of load, stress and displacement value of femoral head necrosis of the femoral head weight-bearing stress value and subsidence value. The necrosis area of stress value increases with the displacement range of 15% and 30%. Necrosis located in the anterior and outer side after upper femoral head stress value and subsidence value, the necrosis area of stress value and displacement value had no significant difference (P0.05). (2) according to the collapse criterion, in ordinary walking, slow running, Run quickly, preoperative and postoperative necrosis of 30% than 15% necrosis of femoral head collapse risk, 4mm 2mm collapse of the femoral head collapse risk of collapse, and with the increasing of load, increase the risk of postoperative collapse. The collapse risk than preoperative collapse risk decreased, but with the increasing of load. Collapse risk. 15% and 30% in the necrosis range before and after the collapse of upper side, the risk is no big difference. Conclusion: (1) the finite element analysis model can effectively simulate the biomechanical changes of tricalcium phosphate ceramic rod system implanted in the femoral head necrosis region. (2) beta tricalcium phosphate bioceramic rod system implantation can effectively improve the mechanical properties of the internal necrosis of the femoral head necrosis, increase the weight-bearing area of femoral head bone support ability, reduce the necrotic bone stress and reduce the risk of collapse of the femoral head necrosis. (3) beta three phosphate bioceramics The ability of the mechanical support rod system is limited, with the increase of the load, necrosis of femoral head collapse risk increases gradually. The smaller is better necrosis and collapse degree of light in a wide range of necrosis and collapse of femoral head necrosis degree. (4) to evaluate the curative effect from a biomechanical perspective, a theoretical basis for beta tricalcium phosphate the ceramic rod system in the treatment of avascular necrosis of the femoral head to provide biomechanical aspects.

【學(xué)位授予單位】：廣西醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R681.8

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