本文選題：股骨轉(zhuǎn)子間骨折 + 有限元分析　； 參考：《廣州中醫(yī)藥大學(xué)》2017年博士論文

【摘要】：目的:隨著生物力學(xué)、材料學(xué)的發(fā)展,股骨轉(zhuǎn)子間骨折的治療也取得了許多進步,多種多樣的內(nèi)固定器械隨之產(chǎn)生,髓內(nèi)釘固定成為了目前股骨轉(zhuǎn)子間骨折的治療主流,但仍無法避免內(nèi)固定失敗的發(fā)生�；仡櫺苑治龉晒寝D(zhuǎn)子間骨折髓內(nèi)釘固定術(shù)后的患者基本臨床資料、骨質(zhì)疏松評級、骨折復(fù)位質(zhì)量、尖頂距等資料,探討股骨轉(zhuǎn)子間骨折髓內(nèi)釘固定后發(fā)生內(nèi)固定失敗的危險因素。有限元分析已被用于內(nèi)固定器械的力學(xué)性能評價,指導(dǎo)醫(yī)療器械的設(shè)計和改造。本研究根據(jù)股骨近端"三角固定"理論設(shè)計了改良股骨近端髓內(nèi)釘。在PFNA-Ⅱ的基礎(chǔ)上調(diào)整螺旋刀片與主釘?shù)慕嵌?同時增加1枚近端抗張力螺釘。通過有限元分析方法比較生理載荷狀態(tài)下改良股骨近端髓內(nèi)釘和PFNA-Ⅱ固定Evans Ⅳ型不穩(wěn)定型股骨轉(zhuǎn)子間骨折的生物力學(xué)性能,檢驗改良股骨近端髓內(nèi)釘設(shè)計的合理性,為新器械的臨床應(yīng)用提供理論依據(jù)及研究思路。方法:選取廣州中醫(yī)藥大學(xué)第一附屬醫(yī)院診斷為股骨轉(zhuǎn)子間骨折并接受閉合復(fù)位髓內(nèi)釘固定的患者,設(shè)定納入標準和排除標準。收集患者年齡、性別、骨折患側(cè)、骨折類型、復(fù)位質(zhì)量、內(nèi)固定種類、尖頂距、內(nèi)固定失敗等臨床資料。采用卡方檢驗等方法比較內(nèi)固定失敗組和內(nèi)固定未失敗組患者的臨床資料之間的差異,通過二元回歸的方法了解骨折內(nèi)固定失敗的危險因素。選取一名健康老年男性志愿者,用螺旋CT對其右側(cè)股骨進行全段薄層掃描。CT影像數(shù)據(jù)導(dǎo)入Mimics 14.1軟件,根據(jù)不同組織灰度值的差異,通過閾值化及像素修補、區(qū)域增長和消除孤立點等處理,分離皮質(zhì)骨、松質(zhì)骨和骨髓腔,利用三維模型生成功能生成股骨中上段三維模型。將股骨中上段三維模型導(dǎo)入逆向工程軟件Geomagic Studio 10.0進行光滑處理網(wǎng)格劃分。將股骨模型導(dǎo)入Abaqus 12.0進行載荷預(yù)實驗,驗證本研究的模型可靠有效。再將股骨模型導(dǎo)入到Solidwork2010軟件中模擬EvansⅣV型骨折進行截骨建立Evans Ⅳ型股骨轉(zhuǎn)子間不穩(wěn)定型骨折模型。在SolidWorks 2010軟件中根據(jù)PFNA-Ⅱ髓內(nèi)釘數(shù)據(jù)尺寸三維重建PFNA-Ⅱ和改良股骨近端髓內(nèi)釘?shù)玫綌?shù)字模型。將Evans Ⅳ型股骨轉(zhuǎn)子間骨折模型及兩種髓內(nèi)釘模型導(dǎo)入SolidWorks 2010中進行裝配,生成改良股骨近端髓內(nèi)釘和PFNA-Ⅱ內(nèi)固定后的模型。髓內(nèi)釘在股骨中的位置以辛迪思所提供手術(shù)操作標準為參考,螺旋刀片位于股骨頭中下靠后位置。然后將骨折內(nèi)固定模型導(dǎo)入到限元分析軟件Abaqus 12.0進行處理分析。參照參考文獻中的材料賦值、邊界條件和加載條件,模擬成人雙足站立位和步態(tài)周期關(guān)節(jié)承載峰值時刻兩種受力情況進行靜態(tài)加載和動態(tài)加載有限元分析。得到兩種內(nèi)固定模型在相同載荷下的內(nèi)固定物的應(yīng)力分布及應(yīng)力峰值、股骨的應(yīng)力分布及應(yīng)力值、內(nèi)固定模型的位移情況及位移值,比較分析兩種不同髓內(nèi)釘固定老年不穩(wěn)定型股骨轉(zhuǎn)子間骨折的生物力學(xué)性能。結(jié)果:共納入107例股骨轉(zhuǎn)子間骨折髓內(nèi)釘閉合復(fù)位固定的患者,男性45例,女性62例,平均年齡為75.07±6.16歲(65歲-90歲)。其中內(nèi)固定失敗組10例,內(nèi)固定未失敗組97例。內(nèi)固定失敗組和內(nèi)固定未失敗組患者在性別比例、骨折患側(cè)、骨折分型、內(nèi)固定方式、骨質(zhì)疏松方面的差異無統(tǒng)計學(xué)意義(P0.05)。兩組患者在年齡、骨折復(fù)位質(zhì)量、尖頂距方面的差異具有統(tǒng)計學(xué)意義(P0.05)。二元回歸顯示尖頂距大于25mm是發(fā)生股骨轉(zhuǎn)子間骨折髓內(nèi)釘內(nèi)固定失敗的唯一危險因素。建立老年Evans Ⅳ型股骨轉(zhuǎn)子間骨折的三維有限元模型、改良股骨近端髓內(nèi)釘及PFAN-Ⅱ兩種髓內(nèi)釘固定股骨轉(zhuǎn)子間骨折后的三維有限元模型。在兩種生理載荷狀態(tài)下,兩種內(nèi)固定模型的應(yīng)力集中均位于頭頸螺釘與主釘交界部位。改良股骨近端髓內(nèi)釘?shù)膬?nèi)固定應(yīng)力值大于PFNA-Ⅱ,靜態(tài)加載和動態(tài)加載情況下兩者的應(yīng)力峰值分別為228.0Mpa、214.4Mpa和618.3Mpa、575.4Mpa。改良股骨近端髓內(nèi)釘固定模型的股骨應(yīng)力峰值大于PFNA-Ⅱ固定模型的股骨應(yīng)力峰值,靜態(tài)加載和動態(tài)加載情況下股骨的應(yīng)力峰值分別為113.4Mpa、95.8Mpa和150.8Mpa、125.8Mpa。兩種加載模式下改良股骨近端髓內(nèi)釘固定模型的位移值較小于PFNA-Ⅱ組,分別為5.01mm、5.37mm和5.18mm、5.59mm。結(jié)論:股骨轉(zhuǎn)子間骨折髓內(nèi)釘固定術(shù)后有較高的內(nèi)固定失敗發(fā)生率。高齡患者、骨折復(fù)位不佳、尖頂距大于25mm時出現(xiàn)內(nèi)固定失敗的風(fēng)險較高。尖頂距是預(yù)測髓內(nèi)釘內(nèi)固定失敗的重要因素。在臨床手術(shù)操作中需要注意控制頭頸螺釘?shù)募忭斁嘈∮?5mm,以降低內(nèi)固定失敗的可能。有限元分析方法可以很好的模擬和驗證新器械的生物力學(xué)性能,具有力學(xué)性能測試全面、可重復(fù)性好等優(yōu)點。對于不穩(wěn)定型Evans Ⅳ型股骨轉(zhuǎn)子間骨折,改良股骨近端髓內(nèi)釘在固定不穩(wěn)定型股骨轉(zhuǎn)子間骨折時具有較好的穩(wěn)定性�？紤]到臨床實際情況,本研究中抗張力螺釘與螺旋刀片之間未產(chǎn)生接觸,導(dǎo)致抗力螺釘、螺旋刀片、髓內(nèi)釘主釘三者之間無法形成閉合三角形結(jié)構(gòu),上方的抗張力螺釘由于更加接近受力點而承受較高應(yīng)力存在導(dǎo)致應(yīng)力峰值較高。有限元分析是對實際情況的一種模擬分析,是將復(fù)雜問題簡單化,仍需要和傳統(tǒng)的離體生物力學(xué)實驗相結(jié)合進行驗證,從而為改良股骨近端髓內(nèi)釘進行正確的評價。
[Abstract]:Objective: with the development of biomechanics and material science, many advances have been made in the treatment of intertrochanteric fracture of the femur, and a variety of internal fixation instruments are produced. Intramedullary nail fixation has become the mainstream of the treatment of intertrochanteric fracture of the femur, but it is still impossible to avoid the failure of internal fixation. The basic clinical data, the rating of osteoporosis, the quality of fracture reduction, the spires and so on were used to investigate the risk factors of internal fixation failure after intramedullary nail fixation of intertrochanteric fractures. Finite element analysis has been used to evaluate the mechanical properties of internal fixation instruments and guide the design and transformation of medical instruments. The proximal intramedullary nail of the femur was designed by the "triangular fixation" theory. On the basis of PFNA- II, the angle of the spiral blade and the main nail were adjusted and 1 proximal tension screws were added. The modified femoral proximal intramedullary nailing and the PFNA- II fixed Evans IV unstable femur rotor were compared by the finite element analysis. The biomechanical properties of intervertebral fractures, the rationality of the modified intramedullary nail design of the femur, and the theoretical basis and research ideas for the clinical application of the new instruments. Methods: selected patients who were diagnosed as intertrochanteric fractures in the First Affiliated Hospital of Guangzhou University of Chinese Medicine and received closed reduction and intramedullary nail fixation were set into standards and exclusion. Criteria. The clinical data of patients' age, sex, fracture side, fracture type, reduction quality, internal fixation type, spires, internal fixation failure were used to compare the difference of clinical data between the internal fixation failure group and the internal fixation unsuccessful group by the chi square test, and the two yuan regression method was used to understand the failure of the internal fixation. The risk factors. A healthy old male volunteer was selected and the.CT image data of the right femur were scanned by spiral CT into Mimics 14.1 software. According to the difference of the gray value of different tissues, the cortical bone, cancellous bone and bone marrow cavity were separated by threshold and pixel repair, regional growth and elimination of isolated points. The three-dimensional model of the three dimensional model is generated to generate the three-dimensional model of the middle and upper part of the femur. The three-dimensional model of the middle and upper part of the femur is introduced into the reverse engineering software Geomagic Studio 10 for smoothing the mesh. The femur model is introduced into the Abaqus 12 for the load pre experiment to verify the reliability and effectiveness of the model. Then the femur model is introduced into the Solidwork2010 soft. A model of unstable intertrochanteric fracture of type Evans IV was established by simulating Evans IV V fracture. In SolidWorks 2010 software, a digital model was obtained by three-dimensional reconstruction of PFNA- II with PFNA- II intramedullary nail data size and modified proximal femoral intramedullary nail. The model of Evans IV interfemoral fracture and two intramedullary nail models were used. SolidWorks 2010 was introduced into the assembly to produce a modified model of the modified proximal femoral nail and PFNA- II internal fixation. The position of the intramedullary nail in the femur was referenced by the operating standard provided by Cindy. The spiral blade was located at the back position of the femoral head. Then the internal fixation model was introduced into the finite element analysis software Abaqus 12. According to the material assignment, boundary conditions and loading conditions in the reference literature, the static loading and dynamic loading finite element analysis of two kinds of stress conditions of the adult bipedal standing position and the gait periodic joint bearing peak load are simulated. The stress distribution and stress of the internal fixtures of the two internal fixed models under the same load are obtained. Peak value, stress distribution and stress value of the femur, displacement and displacement value of internal fixation model, compare and analyze the biomechanical properties of two different intramedullary nails in the fixation of unstable intertrochanteric fracture of the femur. Results: 107 cases of intertrochanteric fracture of femur were included, 45 cases in male, 62 in women, and average year. The age was 75.07 + 6.16 years (65 years old -90 years). Among them, there were 10 cases of internal fixation failure group and 97 cases with internal fixation without failure. There was no statistically significant difference in the sex ratio, fracture side, fracture classification, internal fixation and osteoporosis (P0.05). The two groups were in age, fracture reduction quality, and spires in the two groups. The difference in distance was statistically significant (P0.05). The two yuan regression showed that the spel distance greater than 25mm was the only risk factor for the failure of intramedullary nail internal fixation for intertrochanteric fracture of the femur. A three-dimensional finite element model of the aged Evans IV intertrochanteric fracture of the femur was established, and the modified femoral intramedullary nailing and the two intramedullary nailing of the femoral intertrochanteric were fixed for the fixation of the femur. The three-dimensional finite element model after intervertebral fracture. Under two physiological loads, the stress concentration of the two internal fixation models is located at the junction between the head and neck screw and the main nail. The internal fixation stress of the modified proximal intramedullary nail of the femur is greater than that of PFNA- II. The stress peaks of both static loading and dynamic loading are 228.0Mpa, 214.4Mpa, respectively. The peak femur stress peak of the modified femoral proximal intramedullary nail fixation model was greater than that of the PFNA- II fixed model. The peak stress of the femur under static loading and dynamic loading was 113.4Mpa, 95.8Mpa and 150.8Mpa, and the displacement of the femoral proximal intramedullary nail fixation model under the two loading modes of the femur under static loading and dynamic loading, respectively. The displacement of the femoral proximal femoral nail fixation model under static loading and dynamic loading was the displacement of the femoral proximal intramedullary nail fixation model under the static loading and the dynamic loading conditions, respectively, under the static loading and the dynamic loading conditions of the femur under the static loading and dynamic loading conditions of the femur. The value is less than PFNA- II group, 5.01mm, 5.37mm and 5.18mm, respectively, 5.59mm. conclusion: after intramedullary nail fixation of intertrochanteric fracture, there is a higher failure rate of internal fixation. The risk of internal fixation failure when the fracture reduction is poor and the spires greater than 25mm is higher in the elderly patients. The apical distance is an important factor to predict the failure of intramedullary nail internal fixation. In clinical operation, it is necessary to pay attention to control the tip of head and neck screw less than 25mm to reduce the possibility of failure of internal fixation. The finite element analysis method can well simulate and verify the biomechanical properties of the new apparatus. It has the advantages of comprehensive mechanical test and good repeatability. For unstable type Evans IV type femur intertrochanteric bone The modified proximal femur intramedullary nail has better stability when the intertrochanteric fracture of the femur is fixed. Considering the clinical practice, there is no contact between the tension screw and the spiral blade in this study, which leads to the failure to form a closed triangular structure between the resistance screws, the spiral blade and the intramedullary nail main nail, and the resistance above is not formed between the three. The finite element analysis is an analogue analysis of the actual situation, which is a simplification of the complicated problems and still needs to be combined with the traditional biomechanical experiments to verify the correct evaluation of the improved proximal intramedullary nail for the femur.
【學(xué)位授予單位】：廣州中醫(yī)藥大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2017
【分類號】：R687.3

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