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

【摘要】：研究背景成人高脫位髖關節(jié)發(fā)育不良(Development Dysplasia of the Hip, DDH)可造成雙下肢不等長,髖關節(jié)外展受限,骨盆傾斜,脊柱側彎,力線不正而加速膝關節(jié)退變,嚴重影響患者生活質量。成人高脫位DDH病理復雜,這樣導致在治療上非常棘手,行全髖關節(jié)置換(Total Hip Arthroplasty,THA)是一種較好的辦法。但,由于長期高脫位,尤其是單側股骨頭旋轉中心相對真臼旋轉中心上移大于4cm者,THA治療更加具有挑戰(zhàn)性。股骨頭旋轉中心嚴重上移,與真臼的旋轉中心相距較遠,給全髖關節(jié)置換治療高脫位成人DDH帶來術中復位困難,損傷神經血管的可能性很大,尤其是坐骨神經(Sciatic nerve,SN)損傷有極大的風險。有在假臼重建髖臼杯；短縮股骨截骨；一期松解髖關節(jié)延長肢體,下移股骨頭旋轉中心,二期行THA,等方法。這些方法能夠緩解復位的難度和減少神經損傷的并發(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(Femal Nerve,FN)的張力和增加坐骨神經張力,髖外展和屈膝能降低坐骨神經張力,但是,髖外展屈髖屈膝的組合體位對坐骨神經的影響還有待研究。因此,本研究為了探索客觀的臨床實施依據,特進行此坐骨神經生物力學基礎實驗研究并在臨床中進行進一步研究。研究方法1.高脫位DDH真臼重建非短縮截骨全髖關節(jié)置換復位技術及神經安全管理。在2004年12月與2012年9月間18例高脫位(Crowe's IV型)DDH病例,股骨頭旋轉中心上移大于4cm,股骨近端無彎曲畸形,無肢體神經肌肉疾病。所有患者均獲得本人或其委托人的同意,愿意承擔各種手術風險,構成良好依從性者。予自行設計的會陰橫檔牢固固定患者,復位前一分鐘羅庫溴銨3倍(E95)注射松弛肌肉,復位并髖外展30°屈髖60°屈膝90°嚴格坐骨神經管理。術前記錄股骨頭旋轉中心與真臼旋轉中心的距離和髖關節(jié)Harris評分,進行術前術后比較,應用SPSS15.0軟件進行F檢驗處理數據。2.三維運動模型模擬下肢體位變化對坐骨神經長度的影響。應用螺旋CT采集人體數據,Mimics16.0軟件構建三維運動模型,Geomagic2013軟件后處理,UG9.0軟件進行坐骨神經描點計算髖膝關節(jié)不同體位坐骨神經長度。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,計算三種體位組合的坐骨神經長度。3.犬下肢體位變化對坐骨神經張力和位移影響的生物力學分析。應用4只貴州下司犬,去除盆腔內臟,在骶叢神經與坐骨神經移行處切斷,用無張力細線連接坐骨神經斷端于張力傳感器,測量坐骨神經斷端在下肢伸直位、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°位等體位時的張力和等張力下的位移。應用SPSS15.0軟件進行F檢驗比較各體位組合的坐骨神經近端的張力和位移變化。研究結果1.高脫位DDH真臼重建非短縮截骨全髖置換,應用髖外展30°屈髖60°和屈膝90°,可避免坐骨神經損傷。所有患者獲得隨訪,時間在12月至108月,平均76月。股骨頭旋轉中心均到達真臼旋轉中心,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評分87.3±10.6,術前術后比較有顯著性差異。有4髖因術中假體植入過程中出現輕微劈裂骨折,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髖有坐骨神經不完全損傷,4周后完全恢復。2髖出現小腿以遠感覺運動功能受損,4周后感覺恢復,膝踝關節(jié)出現疼痛,MRI未見異常,2月后對癥處理后好轉。無股神經損傷及其他嚴重并發(fā)癥。2.在三維運動模型模擬中,髖外展30°屈髖60°和屈膝90°時,坐骨神經可延長距離最大。3D運動模型能成功計算髖膝關節(jié)不同體位坐骨神經長度。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,三種體位組合的坐骨神經長度中,坐骨神經長度依次降低,最大差異約27mm。3.在犬的實驗中,髖外展30°屈髖60°和屈膝90°時,坐骨神經張力較小,可位移較大。在髖關節(jié)外展30°前提下,在屈髖60°屈膝120°時,坐骨神經近端張力和位移較�。辉谇y60°屈膝90°時,張力和位移稍微高于屈髖60°屈膝120°時,但是此兩組間比較無統(tǒng)計學意義,兩組間差異無顯著性,P0.05。其他所有組間比較均有統(tǒng)計學意義,P0.05。在髖關節(jié)外展30°屈髖60°屈膝90°位,是張力較小的和位移較大的。研究結論1.能成功實現真臼重建髖臼杯非股骨短縮截骨THA治療高脫位DDH。應用牢固固定病人手術體位、羅庫溴銨松弛肌肉并合理松解軟組織獲得復位,復位時髖內收20°屈髖60°屈膝90°時,復位成功后髖外展30°屈髖60°屈膝90°能避免坐骨神經損傷。2.應用螺旋CT采集人體數據,Mimicsl6.0軟件建三維運動模型,Geomagic2013軟件后處理,UG9.0軟件進行坐骨神經描點模型能成功計算髖膝關節(jié)不同體位坐骨神經長度。髖外展30°屈髖60°和屈膝90°時,能增加在肢體延長中同時增加坐骨神經延長度而減少神經損傷可能。3.在髖膝關節(jié)活動過程中,坐骨神經的張力主要與肢體軟組織張力大小和髖關節(jié)的活動度成正比,與膝關節(jié)活動范圍在0°-120°時成反比。坐骨神經近端的位移主要與肢體軟組織張力大小和髖關節(jié)的活動度成反比,與膝關節(jié)活動范圍在0°-120°時成正比。在外展30°屈髖60°屈膝90°時,有利于下肢神經張力的降低,能較好的避免坐骨神經的損傷。
[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.

【學位授予單位】：第三軍醫(yī)大學
【學位級別】：博士
【學位授予年份】：2015
【分類號】：R687.4

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