本文選題：高脫位　切入點(diǎn)：髖關(guān)節(jié)置換　出處：《第三軍醫(yī)大學(xué)》2015年博士論文　論文類型：學(xué)位論文

【摘要】：研究背景成人高脫位髖關(guān)節(jié)發(fā)育不良(Development Dysplasia of the Hip, DDH)可造成雙下肢不等長,髖關(guān)節(jié)外展受限,骨盆傾斜,脊柱側(cè)彎,力線不正而加速膝關(guān)節(jié)退變,嚴(yán)重影響患者生活質(zhì)量。成人高脫位DDH病理復(fù)雜,這樣導(dǎo)致在治療上非常棘手,行全髖關(guān)節(jié)置換(Total Hip Arthroplasty,THA)是一種較好的辦法。但,由于長期高脫位,尤其是單側(cè)股骨頭旋轉(zhuǎn)中心相對(duì)真臼旋轉(zhuǎn)中心上移大于4cm者,THA治療更加具有挑戰(zhàn)性。股骨頭旋轉(zhuǎn)中心嚴(yán)重上移,與真臼的旋轉(zhuǎn)中心相距較遠(yuǎn),給全髖關(guān)節(jié)置換治療高脫位成人DDH帶來術(shù)中復(fù)位困難,損傷神經(jīng)血管的可能性很大,尤其是坐骨神經(jīng)(Sciatic nerve,SN)損傷有極大的風(fēng)險(xiǎn)。有在假臼重建髖臼杯；短縮股骨截骨；一期松解髖關(guān)節(jié)延長肢體,下移股骨頭旋轉(zhuǎn)中心,二期行THA,等方法。這些方法能夠緩解復(fù)位的難度和減少神經(jīng)損傷的并發(fā)癥,但是也增加了其他的并發(fā)癥。真臼重建非股骨短縮截骨THA在治療高脫位DDH方面,屈髖可以降低股神經(jīng)(Femal Nerve,FN)的張力和增加坐骨神經(jīng)張力,髖外展和屈膝能降低坐骨神經(jīng)張力,但是,髖外展屈髖屈膝的組合體位對(duì)坐骨神經(jīng)的影響還有待研究。因此,本研究為了探索客觀的臨床實(shí)施依據(jù),特進(jìn)行此坐骨神經(jīng)生物力學(xué)基礎(chǔ)實(shí)驗(yàn)研究并在臨床中進(jìn)行進(jìn)一步研究。研究方法1.高脫位DDH真臼重建非短縮截骨全髖關(guān)節(jié)置換復(fù)位技術(shù)及神經(jīng)安全管理。在2004年12月與2012年9月間18例高脫位(Crowe's IV型)DDH病例,股骨頭旋轉(zhuǎn)中心上移大于4cm,股骨近端無彎曲畸形,無肢體神經(jīng)肌肉疾病。所有患者均獲得本人或其委托人的同意,愿意承擔(dān)各種手術(shù)風(fēng)險(xiǎn),構(gòu)成良好依從性者。予自行設(shè)計(jì)的會(huì)陰橫檔牢固固定患者,復(fù)位前一分鐘羅庫溴銨3倍(E95)注射松弛肌肉,復(fù)位并髖外展30°屈髖60°屈膝90°嚴(yán)格坐骨神經(jīng)管理。術(shù)前記錄股骨頭旋轉(zhuǎn)中心與真臼旋轉(zhuǎn)中心的距離和髖關(guān)節(jié)Harris評(píng)分,進(jìn)行術(shù)前術(shù)后比較,應(yīng)用SPSS15.0軟件進(jìn)行F檢驗(yàn)處理數(shù)據(jù)。2.三維運(yùn)動(dòng)模型模擬下肢體位變化對(duì)坐骨神經(jīng)長度的影響。應(yīng)用螺旋CT采集人體數(shù)據(jù),Mimics16.0軟件構(gòu)建三維運(yùn)動(dòng)模型,Geomagic2013軟件后處理,UG9.0軟件進(jìn)行坐骨神經(jīng)描點(diǎn)計(jì)算髖膝關(guān)節(jié)不同體位坐骨神經(jīng)長度。分別在下肢伸直位、髖外展0°屈髖60°屈膝90°和髖外展30°屈髖60°和屈膝90°時(shí),計(jì)算三種體位組合的坐骨神經(jīng)長度。3.犬下肢體位變化對(duì)坐骨神經(jīng)張力和位移影響的生物力學(xué)分析。應(yīng)用4只貴州下司犬,去除盆腔內(nèi)臟,在骶叢神經(jīng)與坐骨神經(jīng)移行處切斷,用無張力細(xì)線連接坐骨神經(jīng)斷端于張力傳感器,測量坐骨神經(jīng)斷端在下肢伸直位、髖外展30°屈髖120°屈膝135°位、髖外展30°屈髖60°屈膝120°位、髖外展30°屈髖60°屈膝90°位、髖外展30°屈髖60°屈膝60°位、髖外展30°屈髖60°屈膝30°位等體位時(shí)的張力和等張力下的位移。應(yīng)用SPSS15.0軟件進(jìn)行F檢驗(yàn)比較各體位組合的坐骨神經(jīng)近端的張力和位移變化。研究結(jié)果1.高脫位DDH真臼重建非短縮截骨全髖置換,應(yīng)用髖外展30°屈髖60°和屈膝90°,可避免坐骨神經(jīng)損傷。所有患者獲得隨訪,時(shí)間在12月至108月,平均76月。股骨頭旋轉(zhuǎn)中心均到達(dá)真臼旋轉(zhuǎn)中心,患肢延長從40mm到68mm(48.65±7.28mm)。雙下肢肢體長度差異0-16mm(5±4mm)。最后一次Harris評(píng)分87.3±10.6,術(shù)前術(shù)后比較有顯著性差異。有4髖因術(shù)中假體植入過程中出現(xiàn)輕微劈裂骨折,立即拔出股骨柄假體,在股骨近端,小粗隆處捆扎鋼纜后,重新植入假體,則獲得牢固的初始穩(wěn)定。3髖有坐骨神經(jīng)不完全損傷,4周后完全恢復(fù)。2髖出現(xiàn)小腿以遠(yuǎn)感覺運(yùn)動(dòng)功能受損,4周后感覺恢復(fù),膝踝關(guān)節(jié)出現(xiàn)疼痛,MRI未見異常,2月后對(duì)癥處理后好轉(zhuǎn)。無股神經(jīng)損傷及其他嚴(yán)重并發(fā)癥。2.在三維運(yùn)動(dòng)模型模擬中,髖外展30°屈髖60°和屈膝90°時(shí),坐骨神經(jīng)可延長距離最大。3D運(yùn)動(dòng)模型能成功計(jì)算髖膝關(guān)節(jié)不同體位坐骨神經(jīng)長度。在下肢伸直位、髖外展0°屈髖60°屈膝90°和髖外展30°屈髖60°和屈膝90°時(shí),三種體位組合的坐骨神經(jīng)長度中,坐骨神經(jīng)長度依次降低,最大差異約27mm。3.在犬的實(shí)驗(yàn)中,髖外展30°屈髖60°和屈膝90°時(shí),坐骨神經(jīng)張力較小,可位移較大。在髖關(guān)節(jié)外展30°前提下,在屈髖60°屈膝120°時(shí),坐骨神經(jīng)近端張力和位移較�。辉谇y60°屈膝90°時(shí),張力和位移稍微高于屈髖60°屈膝120°時(shí),但是此兩組間比較無統(tǒng)計(jì)學(xué)意義,兩組間差異無顯著性,P0.05。其他所有組間比較均有統(tǒng)計(jì)學(xué)意義,P0.05。在髖關(guān)節(jié)外展30°屈髖60°屈膝90°位,是張力較小的和位移較大的。研究結(jié)論1.能成功實(shí)現(xiàn)真臼重建髖臼杯非股骨短縮截骨THA治療高脫位DDH。應(yīng)用牢固固定病人手術(shù)體位、羅庫溴銨松弛肌肉并合理松解軟組織獲得復(fù)位,復(fù)位時(shí)髖內(nèi)收20°屈髖60°屈膝90°時(shí),復(fù)位成功后髖外展30°屈髖60°屈膝90°能避免坐骨神經(jīng)損傷。2.應(yīng)用螺旋CT采集人體數(shù)據(jù),Mimicsl6.0軟件建三維運(yùn)動(dòng)模型,Geomagic2013軟件后處理,UG9.0軟件進(jìn)行坐骨神經(jīng)描點(diǎn)模型能成功計(jì)算髖膝關(guān)節(jié)不同體位坐骨神經(jīng)長度。髖外展30°屈髖60°和屈膝90°時(shí),能增加在肢體延長中同時(shí)增加坐骨神經(jīng)延長度而減少神經(jīng)損傷可能。3.在髖膝關(guān)節(jié)活動(dòng)過程中,坐骨神經(jīng)的張力主要與肢體軟組織張力大小和髖關(guān)節(jié)的活動(dòng)度成正比,與膝關(guān)節(jié)活動(dòng)范圍在0°-120°時(shí)成反比。坐骨神經(jīng)近端的位移主要與肢體軟組織張力大小和髖關(guān)節(jié)的活動(dòng)度成反比,與膝關(guān)節(jié)活動(dòng)范圍在0°-120°時(shí)成正比。在外展30°屈髖60°屈膝90°時(shí),有利于下肢神經(jīng)張力的降低,能較好的避免坐骨神經(jīng)的損傷。
[Abstract]:The research background of adult higher dislocation of hip dysplasia (Development Dysplasia of the Hip, DDH) can be made into double limb length, hip abduction, pelvic tilt, scoliosis, alignment and accelerate the degeneration of the knee, seriously affects the life quality of the patients. The adult higher dislocation DDH pathology is complex, resulting in the treatment of is very difficult, for total hip replacement (Total Hip, Arthroplasty, THA) is a kind of good way. However, due to the long-term high dislocation, especially on one side of the femoral head center true acetabular rotation center up relative greater than 4cm, THA treatment is more challenging. The femoral head center and the rotation center really serious shift the mortar is far apart, for total hip replacement in the treatment of adult DDH with high dislocation reset difficulties, possibility of great damage to nerves and blood vessels, especially the sciatic nerve injury (Sciatic nerve, SN) has a great wind There are risks. In false acetabulum reconstruction of acetabular cup; femoral shortening osteotomy; a loose hip extension of the body, down the center of the femoral head, two stage THA, and other methods. These methods can alleviate the difficulty of the reset and reduce the complication rate, but also increases the complication of others. The true acetabulum reconstruction of femoral shortening osteotomy in the treatment of THA high dislocation DDH, hip flexion can reduce the femoral nerve (Femal Nerve, FN) and increase the tension of the sciatic nerve tension, hip abduction and flexion can reduce the sciatic nerve tension, but the combination of postural hip abduction hip flexion bending effect on sciatic nerve remains to be studied. Therefore, this study in order to explore the objective clinical basis for implementation of the sciatic nerve, the special biomechanical basis of experimental research and further research in clinical research. Methods 1. high dislocation DDH true acetabular reconstruction non shortening osteotomy in Total Hip Arthroplasty replacement Technology and nerve safety management. In December 2004 and September 2012 18 cases of high dislocation (Crowe's IV type) DDH cases, the center of the femoral head up more than 4cm, the proximal femur without bending deformity, no limb neuromuscular disease. All patients got himself or his client's consent, willing to bear all the risk of surgery, a good compliance. Perineum were treated with self-designed fixed rungs, one minute before the reduction of rocuronium 3 times (E95) injection of muscle relaxation, reduction and abduction of hip hip flexion 30 degrees 60 degrees at 90 degrees in strict management. The sciatic nerve was recorded preoperatively femoral head center and the rotation center distance and the true acetabulum the Harris hip score, postoperative comparison, application of SPSS15.0 software for F test data.2. model to simulate the three-dimensional motion of lower limb postural change effect on sciatic nerve length. Application of spiral CT acquisition of human data, Mimics16 The three-dimensional motion model of.0 software, Geomagic2013 software and UG9.0 software for postprocessing, sciatic nerve tracing point calculation of hip and knee position sciatic nerve length. In a straight leg, hip hip flexion 0 degrees 60 degrees at 90 degrees and 30 degrees of hip flexion hip abduction and flexion 60 degrees 90 degrees, biomechanical analysis calculation the length of the sciatic nerve.3. dog leg position change of three kinds of combination of position effect on sciatic nerve tension and displacement. The application of the 4 Guizhou Geji dogs, removal of pelvic visceral, transitional cut in the sacral plexus and sciatic nerve, with no tension in the broken ends of the sciatic nerve connection thread tension sensor, measurement of sciatic nerve stump in straight leg, hip hip flexion 30 degrees 120 degrees at 135 degrees, 30 degrees of hip flexion hip abduction 60 degrees at 120 degrees, 30 degrees of abduction of hip flexion of the hip flexion 60 degrees 90 degrees, 30 degrees of hip flexion hip abduction 60 degrees at 60 degrees, 30 degrees of hip flexion hip abduction 60 degrees 30. The displacement of tension and tension degrees etc. position under tension and displacement. SPSS15.0 software was used for F test comparing the combination of the sciatic nerve proximal position. The results of 1. high dislocation DDH true acetabular reconstruction non shortening osteotomy in total hip arthroplasty, application of hip abduction 30 degrees 60 degrees of knee flexion and hip flexion 90 degrees, can avoid the injury of sciatic nerve. All patients were followed up, the time from December to 108 months, average 76 months. The femoral head center arrives at the true acetabular rotation center, limb extended from 40mm to 68mm (48.65 + 7.28mm). The double lower limb length difference of 0-16mm (5 + 4mm) last time. The Harris score was 87.3 + 10.6, before and after surgery had significant difference. 4 for hip prosthesis implantation in the course of minor fracture, immediately unplug the femoral prosthesis, in the proximal femur lesser trochanter tied cable after reimplantation was strong initial stability.3 hip sit Bone nerve injury, 4 weeks after complete recovery of.2 hip leg sensorimotor function beyond impaired sensory recovery after 4 weeks, knee and ankle joint pain, MRI is no exception, in February after the symptomatic treatment. No femoral nerve injury and other serious complications of.2. in 3D motion simulation, hip abduction 30 60 degrees of hip flexion and knee flexion angle of 90 degrees, the sciatic nerve can extend the maximum distance.3D motion model can successfully calculate the hip and knee position sciatic nerve length. In a straight leg, hip flexion hip abduction 0 degrees 60 degrees at 90 degrees and 30 degrees of hip flexion hip abduction and flexion 60 degrees 90 degrees, three different combination of sciatic nerve length, sciatic nerve length decreased, the biggest difference about 27mm.3. in dogs, hip abduction 30 degrees of hip flexion at 90 degrees and 60 degrees, the sciatic nerve tension can be smaller, larger displacement at the hip. 30 degrees of abduction in the premise of hip flexion 60 degrees at 120 Degrees, the sciatic nerve proximal tension and the displacement is small; in hip flexion 60 degrees at 90 degrees, the tension and displacement is slightly higher than the 60 degrees of hip flexion at 120 degrees, but no statistical significance between the two groups, no significant differences between two groups of P0.05., all the other groups had statistical significance. P0.05. in hip abduction 30 degrees of hip flexion 60 degrees flexion 90 degrees, tension is smaller and larger displacement. The conclusion of the study 1. can achieve the true acetabular reconstruction of acetabular cup femoral shortening osteotomy THA treatment position high dislocation DDH. application fixation surgery, rocuronium muscle relaxation and reasonable the solution of soft tissue gain reduction, reduction of hip adduction 20 degrees of hip flexion 60 degrees at 90 degrees, 30 degrees of abduction of hip after successful reduction of hip flexion 60 degrees at 90 degrees to avoid injury of the sciatic nerve.2. application of spiral CT acquisition of human data, Mimicsl6.0 software to build three-dimensional model, Geomagic2013 software. UG9.0 software, sciatic nerve tracing point model can calculate the hip and knee position sciatic nerve length. Hip abduction 30 degrees of hip flexion at 90 degrees and 60 degrees, can increase during limb lengthening and increase sciatic nerve elongation and reduce nerve injury.3. in hip and knee joint activity during sciatic the main nerve tension and limb soft tissue tension and hip joint activity is proportional to the degree, and the range of motion of knee joint in 0 degrees -120 degrees is inversely proportional to the displacement of the proximal end of the sciatic nerve and limb soft tissue tension and hip joint activities inversely, and the range of motion of knee joint in 0 ~ -120 the degree is proportional to. In 30 degrees of abduction of hip flexion 60 degrees at 90 degrees, can reduce lower extremity nerve tension, can better avoid the sciatic nerve injury.

【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2015
【分類號(hào)】：R687.4

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