本文選題：膝關(guān)節(jié) + 假體��； 參考：《第二軍醫(yī)大學(xué)》2017年博士論文

【摘要】：研究背景膝關(guān)節(jié)是人體下肢的樞紐關(guān)節(jié),其復(fù)雜組織解剖結(jié)構(gòu)、運(yùn)動(dòng)模式和所處的力學(xué)環(huán)境及其功能要求使其易受創(chuàng)傷和骨性關(guān)節(jié)炎等疾病累及,傷病發(fā)生率居各關(guān)節(jié)之首。人工全膝關(guān)節(jié)置換術(shù)(Total Knee Arthroplasty,TKA或Total Knee Replacement,TKR)是采用手術(shù)的方法將病損的膝關(guān)節(jié)負(fù)重面替換為人工關(guān)節(jié)材料,從而消除膝關(guān)節(jié)疼痛、恢復(fù)下肢生理力線、改善膝關(guān)節(jié)活動(dòng)功能。TKA是骨科最成功的經(jīng)典手術(shù)之一,它使過(guò)去只能依賴藥物緩解疼痛無(wú)法長(zhǎng)距離行走,甚至只能截肢的患者恢復(fù)了行走功能,大大改善了患者的生活質(zhì)量。TKA不僅僅是骨的手術(shù),更是軟組織的手術(shù),下肢力線精確重建、假體位置正確安置是影響術(shù)后關(guān)節(jié)功能和假體使用壽命的重要因素,對(duì)評(píng)估手術(shù)成敗和術(shù)后療效有重要的參考價(jià)值。為了提高TKA術(shù)中下肢力線重建的準(zhǔn)確性,大量的醫(yī)療衛(wèi)生資源和研究精力被投入到術(shù)中計(jì)算機(jī)輔助導(dǎo)航技術(shù)和個(gè)體化手術(shù)工具(patient specific instrument,PSI)的研究中。人工全膝關(guān)節(jié)置換領(lǐng)域傳統(tǒng)的觀點(diǎn)認(rèn)為TKA術(shù)后患者下肢力線應(yīng)重建至與中立位力線偏差小于3°的位置。近年來(lái)有很多術(shù)后隨訪研究發(fā)現(xiàn)TKA術(shù)后重建的下肢力線無(wú)論是否與中立位力線偏差在3°以內(nèi),患者術(shù)后的人工關(guān)節(jié)假體生存率并無(wú)顯著差異。這些研究結(jié)果讓研究者們開(kāi)始思考TKA對(duì)線標(biāo)準(zhǔn)是否存在不足,Howell等一些學(xué)者更進(jìn)一步提出了運(yùn)動(dòng)力學(xué)對(duì)線TKA(Kinematical Alignment TKA,KA-TKA)概念,即TKA應(yīng)以患者膝關(guān)節(jié)正常狀態(tài)的或病損前狀態(tài)的運(yùn)動(dòng)軸為對(duì)線、定位參考進(jìn)行截骨、假體安置,從而在術(shù)后使人工膝關(guān)節(jié)盡可能的模擬人體膝關(guān)節(jié)正常的生物力學(xué)狀態(tài)。目前KA-TKA成為關(guān)注的熱點(diǎn)是因?yàn)榻?jīng)典的MA-TKA術(shù)后出現(xiàn)了較高的不滿意率。從理論上說(shuō),相對(duì)于MA-TKA的機(jī)械力學(xué)對(duì)線方式,KA-TKA的運(yùn)動(dòng)力學(xué)對(duì)線方式能最大程度的恢復(fù)患者的膝關(guān)節(jié)生物力學(xué)和運(yùn)動(dòng)力學(xué)環(huán)境,從而獲得更好的手術(shù)效果和臨床療效,但目前相關(guān)臨床和基礎(chǔ)研究還遠(yuǎn)遠(yuǎn)不足以充分的證明這一觀點(diǎn),KA-TKA是否更具優(yōu)勢(shì),尚需進(jìn)一步研究驗(yàn)證。第一部分:人體膝關(guān)節(jié)和人工膝關(guān)節(jié)真幾何模型和有限元模型的建立目的:建立人體膝關(guān)節(jié)和TKA假體仿真幾何模型和有限元模型,為進(jìn)行膝關(guān)節(jié)和TKA術(shù)后的生物力學(xué)分析建立基礎(chǔ)。方法:選擇一名健康成年人志愿者,使用CT進(jìn)行左側(cè)下肢全長(zhǎng)掃描,MRI進(jìn)行膝關(guān)節(jié)掃描,獲取醫(yī)學(xué)影像數(shù)據(jù),利用Mimics15.0、UG NX 7.0、ABAQUS 6.8等圖像處理分析軟件和有限元分析軟件,重建了人體膝關(guān)節(jié)仿真幾何模型,在此幾何模型基礎(chǔ)上,運(yùn)用有限元軟件構(gòu)建膝關(guān)節(jié)的有限元模型。利用逆向工程技術(shù)和Geomagic Studio 9.0軟件將施樂(lè)輝公司(SmithNephew Inc.)Genesis II后穩(wěn)定型人工全膝關(guān)節(jié)假體的外形掃描數(shù)據(jù)重建為幾何模型,將其和膝關(guān)節(jié)模型進(jìn)行裝配,獲得人工全膝關(guān)節(jié)置換術(shù)后膝關(guān)節(jié)幾何模型和有限元模型。結(jié)果:建立了適用于進(jìn)行膝關(guān)節(jié)和人工全膝關(guān)節(jié)置換術(shù)后生物力學(xué)分析的解剖型仿真幾何模型和有限元模型。結(jié)論:本研究利用CT、MRI影像數(shù)據(jù)和逆向工程技術(shù)所建立的人體膝關(guān)節(jié)和人工膝關(guān)節(jié)假體仿真幾何模型和有限元模型,與人體膝關(guān)節(jié)解剖結(jié)構(gòu)一致,可逼真的重現(xiàn)膝關(guān)節(jié)的真實(shí)結(jié)構(gòu),用于TKA手術(shù)仿真、模擬并進(jìn)行生物力學(xué)分析。第二部分:運(yùn)動(dòng)力學(xué)與機(jī)械力學(xué)對(duì)線的人工膝關(guān)節(jié)生物力學(xué)分析目的:有限元分析比較運(yùn)動(dòng)力學(xué)對(duì)線和機(jī)械力學(xué)對(duì)線的人工全膝關(guān)節(jié)置換術(shù)術(shù)后生物力學(xué)特性,重點(diǎn)探討兩種對(duì)線方式下人工關(guān)節(jié)接觸面的應(yīng)力和應(yīng)變情況。方法:隨機(jī)選擇12名健康成年人志愿者,根據(jù)第一部分的建模方法,獲取志愿者左側(cè)膝關(guān)節(jié)仿真幾何模型和有限元模型,選擇合適大小的人工全膝關(guān)節(jié)假體,按運(yùn)動(dòng)力學(xué)對(duì)線方式和機(jī)械力學(xué)對(duì)線方式分別進(jìn)行虛擬截骨、假體安裝,通過(guò)有限元分析軟件仿真單足站立情形施加載荷,觀察人工關(guān)節(jié)假體接觸面的最大應(yīng)力和最大應(yīng)變情況。結(jié)果:按機(jī)械力學(xué)對(duì)線(MA)方式放置安裝假體后,股骨假體接觸表面最大應(yīng)力為38.25±2.66MPa,,按運(yùn)動(dòng)力學(xué)對(duì)線(KA)方式安置假體后,最大應(yīng)力減小為30.37±2.76MPa,差異具有統(tǒng)計(jì)學(xué)意義,P0.05。在超高分子聚乙烯墊片表面,MA方式時(shí)最大應(yīng)力為12.07±1.67MPa,KA方式時(shí)最大應(yīng)力減小為8.14±2.49MPa,差異具有統(tǒng)計(jì)學(xué)意義,P0.05。在MA方式下股骨假體接觸表面最大應(yīng)變?yōu)?.51x10~(-4)±1.09x10-5mm,KA方式時(shí)最大應(yīng)變?yōu)?.18x10-5±1.05x10-5mm,小于MA方式時(shí)的形變,差異具有統(tǒng)計(jì)學(xué)意義,P0.05。在超高分子聚乙烯墊片表面,MA方式時(shí)最大應(yīng)變?yōu)?.43x x10~(-3)±5.12x10~(-4)mm,KA方式時(shí)應(yīng)變減小,為2.10 x10~(-3)±3.86x10~(-4)mm,差異具有統(tǒng)計(jì)學(xué)意義,P0.05。結(jié)論:與傳統(tǒng)機(jī)械力學(xué)對(duì)線方式相比,按運(yùn)動(dòng)力學(xué)對(duì)線方式進(jìn)行人工全膝關(guān)節(jié)置換術(shù)可降低股骨假體和脛骨聚乙烯襯墊表面的最大應(yīng)力和最大應(yīng)變,使人工關(guān)節(jié)接觸面壓力分布更均勻,從而減少關(guān)節(jié)接觸面的磨損,延長(zhǎng)假體壽命。
[Abstract]:The knee joint is the hinge joint of the lower limbs of the human body. The complex anatomical structure of the knee, the mode of motion, the mechanical environment and its function requirements make it susceptible to the diseases such as trauma and osteoarthritis, and the incidence of injury is the first. Total knee arthroplasty (Total Knee Arthroplasty, TKA or Total Knee Replacemen) T, TKR) is an operation method to replace the damaged surface of the knee joint as artificial joint material, so as to eliminate the pain of the knee joint, restore the physiological force line of the lower limbs, and improve the function of the knee joint,.TKA is one of the most successful classic operations in the Department of orthopedics. It can only rely on drugs to relieve pain and can not walk long distance, or even amputate only. The patients recovered the walking function, which greatly improved the patient's quality of life.TKA not only the bone operation, but also the soft tissue operation, the accurate reconstruction of the lower limb force line, the correct placement of the prosthesis position is an important factor affecting the postoperative joint function and the life of the prosthesis. It has important reference value for evaluating the success and failure of hand operation and the postoperative effect. To improve the accuracy of the reconstruction of the lower limb force line in TKA, a large number of medical and health resources and research energy have been put into the study of the patient specific instrument (PSI). The traditional point of view in the field of artificial total knee arthroplasty is that the lower limb force line of the patients after TKA should be rebuilt to the middle of the operation. In recent years, many postoperative follow-up studies have found that there is no significant difference in the survival rate of the artificial joint prosthesis after the TKA reconstruction of the lower limb force line within 3 degrees, whether or not the deviation of the force line between the TKA and the neutral force line is within 3 degrees. These results allow the researchers to begin to think about the deficiency of the TKA line standard, H Owell and other scholars have further proposed the concept of motion mechanics to line TKA (Kinematical Alignment TKA, KA-TKA), that is, TKA should be the alignment of the normal state of the knee joint or the motion axis of the condition before the disease, locating the reference for osteotomy and prosthesis placement, so as to make the artificial knee joint as possible as possible to simulate the normal knee joint of the human body after the operation. Biomechanical state. At present, KA-TKA has become the focus of attention because of the high dissatisfaction rate after the classical MA-TKA. In theory, compared with the mechanical mechanics of MA-TKA, the motion mechanics of KA-TKA can maximize the recovery of the mechanical and mechanical environment of the knee joint of the patient. The effect of operation and clinical efficacy, but the current related clinical and basic research is still far from sufficient proof of this view, whether KA-TKA is more advantageous and still needs further research. Part 1: the establishment of the true geometric model and the finite element model of the human knee joint and the artificial knee joint: the establishment of the human knee joint and the TKA prosthesis. The real geometric model and the finite element model set up the basis for the biomechanical analysis of the knee joint and TKA. Methods: a healthy adult volunteer was selected, CT was used to scan the left lower limb full length scan, the MRI was scanned for the knee joint, the medical image data were obtained, and the image processing analysis software, such as Mimics15.0, UG NX 7, ABAQUS 6.8 and so on, was used. The finite element analysis software is used to reconstruct the simulation geometric model of the human knee joint. On the basis of this geometric model, the finite element model of the knee joint is constructed with the finite element software. The shape scanning of the stable artificial total knee prosthesis after SmithNephew Inc. Genesis II is used by reverse engineering and Geomagic Studio 9 software. The geometric model and the knee joint model were assembled to obtain the geometric model and finite element model of the knee joint after total knee arthroplasty. Results: an anatomical model and finite element model for biomechanical analysis of the knee and total knee replacement were established. Conclusion: This study The simulation geometric model and finite element model of the human knee joint and artificial knee joint prosthesis established by CT, MRI image data and reverse engineering technology are consistent with the anatomical structure of the human knee joint. It can realistically reproduce the true structure of the knee joint. It is used for the simulation of TKA operation, simulation and biomechanical analysis. The second part: the motion mechanics and the biomechanics analysis. Biomechanical analysis of the artificial knee joint with mechanical mechanics. The finite element analysis is used to compare the biomechanical characteristics of the artificial total knee replacement after the line and mechanic mechanics to the line by finite element analysis. The stress and strain situation of the contact surface of the artificial joints under two lines are discussed. Method: 12 healthy adult chronicles are selected randomly. According to the modeling method of the first part, the volunteers can obtain the simulated geometric model and finite element model of the left knee joint of the volunteers, select the suitable artificial total knee prosthesis, carry out the virtual osteotomy, the installation of the prosthesis on the line mode and the mechanical mechanics according to the motion mechanics, and simulate the standing situation by the finite element analysis software. The maximum stress and maximum strain on the contact surface of artificial joint prosthesis were observed. Results: the maximum stress of the contact surface of the femoral prosthesis was 38.25 + 2.66MPa, and the maximum stress was reduced to 30.37 + 2.76MPa according to the mechanical mechanical pair of prosthesis (MA), and the difference was statistically significant. The maximum stress of P0.05. on the surface of ultra-high polymer polyethylene gasket is 12.07 + 1.67MPa, and the maximum stress decreases at 8.14 + 2.49MPa in KA mode, and the difference is statistically significant. The maximum strain of P0.05. in MA mode is 1.51x10~ (-4) + 1.09x10-5mm, and the maximum strain of KA mode is 8.18x10-5 +. Mm, the deformation of less than MA is statistically significant. The maximum strain of P0.05. on the surface of ultra-high polymer polyethylene gasket is 3.43x x10~ (-3) + 5.12x10~ (-4) mm and KA mode. The difference has statistical significance. The difference has statistical significance. Artificial total knee replacement with motion mechanics can reduce the maximum stress and maximum strain on the surface of the femoral prosthesis and tibial polyethylene pad, and make the pressure distribution more uniform on the contact surface of the artificial joints, thus reducing the wear of the joint contact surface and prolonging the life of the prosthesis.

【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R687.4

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