發(fā)布時間：2018-03-13 14:24

  本文選題：股骨轉(zhuǎn)子間內(nèi)側(cè)壁　切入點：股骨轉(zhuǎn)子間外側(cè)壁　出處：《山西醫(yī)科大學(xué)》2017年博士論文　論文類型：學(xué)位論文

【摘要】：第一部分壓力狀態(tài)下股骨轉(zhuǎn)子間內(nèi)側(cè)壁及外側(cè)壁受力的生物力學(xué)研究目的:本部分研究通過對離體股骨標(biāo)本轉(zhuǎn)子間進(jìn)行內(nèi)側(cè)壁或外側(cè)壁缺損造模,測定并比較內(nèi)側(cè)壁或外側(cè)壁缺損后以及經(jīng)過載斷裂后行股骨近端防旋髓內(nèi)釘(PFNA)內(nèi)固定后股骨轉(zhuǎn)子間的力學(xué)負(fù)載及應(yīng)變變化。方法:將納入研究的12對離體股骨標(biāo)本隨機分為內(nèi)側(cè)壁組和外側(cè)壁組,并對每組內(nèi)股骨標(biāo)本行骨密度(BMD)測定。隨機挑選一側(cè)股骨,按分組行股骨轉(zhuǎn)子間內(nèi)側(cè)壁或外側(cè)壁缺損造模處理。在PFNA植入前后,利用單軸應(yīng)變片對股骨轉(zhuǎn)子間的應(yīng)變分布進(jìn)行測量。使用力學(xué)實驗機模擬單足站立時角度施加軸向載荷,直至達(dá)到破壞載荷。在350 N、700 N、1800 N的載荷水平及破壞載荷下分別記錄每個股骨樣本的軸向位移以及各測試點的應(yīng)變值,并計算軸向剛度。將內(nèi)、外側(cè)壁組中數(shù)據(jù)匯總并判斷其可比性后,比較分析內(nèi)外側(cè)壁組間的破壞載荷、軸向剛度以及各測試點的應(yīng)變值。結(jié)果:所有內(nèi)側(cè)壁組及外側(cè)壁組納入的股骨樣本其破壞載荷在不同狀態(tài)之間均有顯著差異(p0.05)。行PFNA內(nèi)固定后,其提供的軸向破壞載荷高達(dá)4.5倍體重左右,可滿足日常活動需要。當(dāng)股骨轉(zhuǎn)子間內(nèi)側(cè)皮質(zhì)缺損后,其所受應(yīng)力應(yīng)變主要集中于前側(cè)、外側(cè)以及后側(cè)皮質(zhì),尤以后側(cè)皮質(zhì)為著;當(dāng)行PFNA內(nèi)固定術(shù)后,其所受應(yīng)力應(yīng)變主要集中于前側(cè)皮質(zhì),并較缺損組股骨能減小其在內(nèi)側(cè)皮質(zhì)所受應(yīng)變,且能撤銷其在外側(cè)以及后側(cè)皮質(zhì)的應(yīng)力集中。當(dāng)股骨轉(zhuǎn)子間外側(cè)皮質(zhì)缺損后,其所受應(yīng)力應(yīng)變主要集中于內(nèi)側(cè)以及后側(cè)皮質(zhì),尤以后側(cè)皮質(zhì)為著;當(dāng)行PFNA內(nèi)固定術(shù)后,其所受應(yīng)力應(yīng)變主要集中于前側(cè)皮質(zhì),并較缺損組股骨能減小其在內(nèi)側(cè)及后側(cè)皮質(zhì)所受應(yīng)變值,撤銷其應(yīng)力集中。結(jié)論:當(dāng)股骨轉(zhuǎn)子間內(nèi)側(cè)壁或外側(cè)壁缺損后,其破壞載荷、軸向剛度均明顯減少。而PFNA作為一種治療股骨轉(zhuǎn)子間骨折的方式,其提供的軸向破壞載荷可滿足日�；顒有枰�。股骨轉(zhuǎn)子間內(nèi)側(cè)壁較外側(cè)壁更為重要,其存在與完整可增加股骨破壞載荷、維持股骨軸向剛度,降低PFNA術(shù)后股骨轉(zhuǎn)子間前后側(cè)皮質(zhì)間的應(yīng)變差距。而前側(cè)皮質(zhì)可能是PFNA置入后維持其穩(wěn)定性的重要原因。第二部分髓內(nèi)釘固定和髖關(guān)節(jié)置換治療股骨轉(zhuǎn)子間骨折的薈萃分析目的:目前,對股骨轉(zhuǎn)子間骨折行髓內(nèi)釘固定與髖關(guān)節(jié)置換術(shù)治療的研究越來越多,但兩種治療方法間仍然存在爭議。本研究目的在于,通過薈萃分析(Meta分析)研究方法,對這兩種治療股骨轉(zhuǎn)子間骨折方法的有效性及安全性做一綜合性分析與判斷,從而能使之更好的服務(wù)于臨床決策。方法:根據(jù)既定的納入標(biāo)準(zhǔn)與排除標(biāo)準(zhǔn),在1980年1月至2016年9月的時間范圍內(nèi)對Pub Med,Embase和Cochrane Library數(shù)據(jù)庫中搜索相關(guān)研究,并限定為英文文獻(xiàn)。使用Review Manager 5.3軟件進(jìn)行兩種治療方法間術(shù)中信息和術(shù)后結(jié)果的對比分析。結(jié)果:本研究共納入符合入選標(biāo)準(zhǔn)的11項研究共1239例患者。與髓內(nèi)釘固定相比,使用髖關(guān)節(jié)置換術(shù)治療股骨轉(zhuǎn)子間骨折,可以減少內(nèi)置物相關(guān)并發(fā)癥(OR:2.05,p=0.02)以及降低再手術(shù)率(OR:7.06,p0.001)。同時髖關(guān)節(jié)置換與髓內(nèi)釘固定具有相似的住院時間(WMD:-0.41,p=0.63)。然而,髓內(nèi)釘固定與髖關(guān)節(jié)置換相比,可明顯減少術(shù)中出血量(WMD:-375.01,p=0.001)和輸血例數(shù)(OR:0.07,p0.001),縮短手術(shù)時間(WMD:-18.92,p=0.010),提高術(shù)后髖關(guān)節(jié)Harris評分(WMD:4.19,p0.001),降低術(shù)后1年內(nèi)死亡率(OR:0.67,p=0.02)。結(jié)論:目前,股骨轉(zhuǎn)子間骨折的主流治療方法仍是髓內(nèi)釘固定。在沒有明確指征的情況下,應(yīng)慎重選擇髖關(guān)節(jié)置換術(shù),并應(yīng)知曉髖關(guān)節(jié)置換術(shù)在老年患者中的復(fù)雜性與風(fēng)險。
[Abstract]:The first part studied inbiomechanical objective under pressure of femoral intertrochanteric medial and lateral wall stress: this part of the study based on the inner wall or outer wall defect model of isolated femoral intertrochanteric specimens, to determine and compare the inner wall or outer wall defect after and after loading fracture underwent proximal femoral antirotation nail (PFNA) internal fixation of intertrochanteric mechanical load and strain changes. Methods: the study of 12 isolated femur specimens were randomly divided into medial wall and lateral wall of group group, and each group of specimens of femoral bone mineral density (BMD) were randomly selected. The side of the femoral, grouped by femoral intertrochanteric medial wall or lateral wall defect model. In the PFNA before and after implantation, to measure the strain distribution of femoral intertrochanteric with uniaxial strain gauges. Simulation of single foot stand when the angle of axial load applied by the mechanical testing machine, until the The failure load. At 350 N, 700 N, strain axial displacement were recorded each femur sample load level and load of 1800 N and the value of each test point, and calculate the axial stiffness of the lateral wall. Within the group data collection and determine the comparability, comparative analysis of the failure load and lateral the wall between the groups, the axial stiffness and strain values of each test point. Results: all the medial wall and lateral wall of the group were included in the failure load of femoral samples in different states have significant differences between (P0.05) PFNA. After fixation, the axial load of up to 4.5 times the weight, can meet the needs of daily activities. When the intertrochanteric medial cortical defect, the stress strain mainly concentrated in the front, lateral and posterior cortex, especially the cortex is; when PFNA fixation, the stress strain mainly concentrated in the anterior cortex, And a group of femoral defect can decrease by the strain in the medial cortex, and can cancel the outside and the stress concentration of the posterior cortex. When intertrochanteric lateral cortical defect, the stress strain mainly concentrated in the medial and posterior cortex, especially the cortex to do; PFNA internal fixation then, the stress and strain are mainly concentrated in the anterior cortex, and femoral defect group can reduce the strain values in the medial and posterior cortex, cancel the stress concentration. Conclusion: when the intertrochanteric medial wall or lateral wall defect, the failure load, the axial stiffness was significantly reduced. PFNA as a way of treating intertrochanteric fractures, which provides axial failure load can meet the needs of daily activities. The intertrochanteric medial wall of the outer wall is more important, its existence and integrity can be increased femoral fracture load, maintain the axial stiffness of the femur, Reduce the PFNA postoperative femoral intertrochanteric anterior and posterior cortex of the anterior cortical strain gap. And may be an important factor to maintain its stability after PFNA implantation. Screw fixation and hip replacement in the treatment of femoral intertrochanteric fractures: a meta analysis to second part intramedullary: at present, more and more research on fixation and treatment of hip replacement intramedullary nailing for femoral fracture between the rotor, but the two kinds of treatment methods are still controversial. The purpose of this study is, through meta analysis (Meta analysis) method of the two methods of treatment of intertrochanteric fractures of the efficacy and safety of doing a comprehensive analysis and judgment, so as to make it better the service in clinical decision making. Methods: according to the inclusion criteria and the exclusion criteria, from January 1980 to September 2016 the time range of Pub Med, Embase Cochrane and related research search in the Library database, and Limited to English literature. The comparative analysis of the results of the two methods in the treatment of information and postoperative patients after using Review Manager 5.3 software. Results: the study included 11 study inclusion criteria with a total of 1239 cases of patients with intramedullary nail fixation compared with hip arthroplasty for the treatment of femoral intertrochanteric fracture, can to reduce the complications related to (OR:2.05, p=0.02) and lower reoperation rate (OR:7.06, p0.001). At the same time, hip replacement and intramedullary nailing with similar hospitalization time (WMD:-0.41, p=0.63). However, intramedullary nail fixation and hip replacement, can significantly reduce the amount of bleeding (WMD:-375.01 p=0.001) and blood transfusion cases (OR:0.07, p0.001), shorten the operation time (WMD:-18.92, p=0.010), improve the postoperative Harris hip score (WMD:4.19, p0.001), reduce the mortality rate within 1 years after surgery (OR: 0.67, p=0.02). Conclusion: the intertrochanteric bone The main way of treatment is the intramedullary nailing. If there is no definite indication, we should carefully choose hip arthroplasty, and we should know the complexity and risk of hip replacement in elderly patients.

【學(xué)位授予單位】：山西醫(yī)科大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2017
【分類號】：R687

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