本文選題：髖臼骨折 + 老年人��； 參考：《蘇州大學(xué)》2015年博士論文

【摘要】：第一部分老年髖臼骨折的流行病學(xué)及臨床影像學(xué)特征目的:分析老年髖臼骨折的流行病學(xué)特征,并比較老年與年輕髖臼骨折的臨床與影像學(xué)特征。方法:回顧分析1990年1月至2013年12月,蘇州大學(xué)附屬第一醫(yī)院收治髖臼骨折患者的臨床資料。根據(jù)一定的納入與排除標(biāo)準(zhǔn),共637例(637髖)髖臼骨折納入分析。根據(jù)患者年齡不同,將患者分為老年髖臼骨折(年齡大于或等于60周歲)和年輕髖臼骨折(年齡小于60周歲)。評估老年髖臼骨折年發(fā)生率、及髖臼骨折患者年齡變化趨勢,老年與年輕髖臼骨折患者合并其他損傷分布情況,老年與年輕髖臼骨折的損傷機制特點,老年與年輕髖臼骨折類型分布特點,及老年與年輕髖臼骨折影像學(xué)特征。結(jié)果:637例髖臼骨折中,老年髖臼骨折133例,年輕髖臼骨折504例。從1990年至2013年,老年髖臼骨折發(fā)生率顯著增加,由1990年的6.7%增加到2013年的40.0%(p=0.021);髖臼骨折患者年平均年齡由1990年的(40.9±9.2)歲增加到2013年的(49.8±15.6)歲(p=0.045);從早期(1990~2000年)到后期(2001~2013年),老年患髖臼骨折發(fā)生率增加1.7倍(14.1%vs.24.1%,p=0.004)。老年髖臼骨折合并其他損傷的發(fā)生率明顯低于年輕髖臼骨折(27.1%vs.48.8%,p=0.000)。老年髖臼骨折常見損傷機制為同一水平面的跌傷(即站立位高度跌傷),占36.1%,而年輕髖臼骨折跌傷所致者僅占0.2%(p=0.000)。老年患者前壁骨折(8.3%vs.1.0%,p=0.000)、前柱骨折(10.5%vs.4.8%,p=0.013)、前柱+后半橫形骨折(3.8%vs.0.4%,p=0.005)發(fā)生率顯著高于年輕患者。老年髖臼骨折除髖關(guān)節(jié)后脫位發(fā)生率顯著低于年輕患者外(16.5%vs.31.9%,p=0.000),其他諸如方形區(qū)骨折(23.3%vs.3.2%,p=0.000)、海鷗征(21.1%vs.0.8%,p=0.000)、髖關(guān)節(jié)前脫位(21.8%vs.10.3%,p=0.000)、股骨頭損傷(13.5%vs.4.6%,p=0.000)、粉碎性后壁骨折(10.5%vs.3.6%,p=0.001)、后壁邊緣壓縮性骨折(12.0%vs.3.2%,p=0.000)等影像學(xué)特征的發(fā)生率均顯著高于年輕患者。結(jié)論:髖臼骨折中老年患者的比例以及髖臼骨折患者年齡均呈上升趨勢;老年髖臼骨折合并其他損傷的發(fā)生率、損傷機制、骨折類型、影像學(xué)特征均與年輕患者不同�？紤]到老年髖臼骨折常合并影響臨床療效的影像學(xué)特征,因此對于老年髖臼骨折,要根據(jù)骨折類型、影像學(xué)特征等情況作出最佳醫(yī)療決策,以便患者獲得較滿意的臨床療效。鑒于跌傷是導(dǎo)致老年髖臼骨折最常見原因,因此日常生活中要注意采取針對性措施,預(yù)防老年人跌倒事件發(fā)生。第二部分影響老年髖臼骨折手術(shù)療效的因素分析目的:切開復(fù)位內(nèi)固定治療老年移位髖臼骨折的臨床療效還存在爭論,并且認(rèn)為如果老年髖臼骨折合并一些影像學(xué)特征,則預(yù)后較差。但是,何種特征是決定老年髖臼骨折術(shù)后療效的關(guān)鍵因素,目前仍不清楚。因此,本研究旨在眾多影響因素中,通過統(tǒng)計學(xué)分析,確定影響切開復(fù)位內(nèi)固定治療老年髖臼骨折預(yù)后的關(guān)鍵因素。方法:對1990年5月至2010年6月,因移位髖臼骨折采用切開復(fù)位內(nèi)固定治療的老年患者進(jìn)行回顧性分析。按照一定的納入與排除標(biāo)準(zhǔn),共86例(86髖)患者納入最終分析,其中男71例,女15例;手術(shù)時年齡60~90歲,平均(67.7±7.3)歲。術(shù)后骨折復(fù)位質(zhì)量采用Matta's標(biāo)準(zhǔn)、臨床功能的評估采用改良Merle D’Aubigne-Postel評分。根據(jù)既往文獻(xiàn)報道,將骨折復(fù)位質(zhì)量及以下6個影像學(xué)特征作為相關(guān)影響因素納入分析,包括方形區(qū)骨折、海鷗征、髖關(guān)節(jié)后脫位、股骨頭損傷、粉碎性后壁骨折及后壁邊緣壓縮性骨折。結(jié)果:隨訪時間2~198個月,平均39個月。末次隨訪時,髖臼骨折合并有上述6個影像學(xué)特征者,平均改良Merle D’Aubigne-Postel評分為(14.4±3.1)分;無這些影像學(xué)特征者,平均改良Merle D’Aubigne-Postel評分為(17.2±1.6)分。末次隨訪時,86例患者中,骨折解剖復(fù)位、復(fù)位不良及復(fù)位差者,平均改良Merle D’Aubigne-Postel評分分別為(16.8±2.4)分、(14.5±2.3)分及(11.3±1.4)分。多元逐步回歸模型分析顯示骨折復(fù)位質(zhì)量(t=-10.45,p=0.000)、粉碎性后壁骨折(t=-2.74,p=0.008)及股骨頭損傷(t=-3.51,p=0.000)是影響切開復(fù)位內(nèi)固定治療老年髖臼骨折預(yù)后的關(guān)鍵因素。結(jié)論:術(shù)前髖臼骨折合并后壁粉碎性骨折及股骨頭損傷是影響切開復(fù)位內(nèi)固定治療老年髖臼骨折預(yù)后的獨立危險因素;而術(shù)后骨折復(fù)位質(zhì)量是切開復(fù)位內(nèi)固定治療老年髖臼骨折臨床療效的獨立預(yù)測因素,如術(shù)后骨折能夠獲得解剖復(fù)位,則可預(yù)測患者術(shù)后療效較滿意。第三部分髖臼方形區(qū)骨折新型復(fù)位內(nèi)固定器的研制與生物力學(xué)比較研究目的:盡管目前存在多種治療髖臼方形區(qū)骨折的內(nèi)固定器,但是對于骨質(zhì)疏松性、粉碎性、及游離性方形區(qū)骨折的治療仍存在挑戰(zhàn)。本研究目的是評估我們自行設(shè)計的一種新的治療髖臼方形區(qū)骨折的內(nèi)固定器的生物力學(xué)特性,并將其與目前存在治療方形區(qū)骨折的其他5種內(nèi)固定器生物力學(xué)特性進(jìn)行比較。方法:取第四代人工合成的半骨盆標(biāo)本十具,并制作成單純方形區(qū)骨折模型,將半骨盆固定在特制的夾具上,使髖臼開口水平向上,放置于英斯特朗E10000拉扭雙軸電子萬能材料力學(xué)試驗機上,依次測試下述六種治療髖臼方形區(qū)骨折內(nèi)固定的生物力學(xué)特性:(1)單向鉸鏈?zhǔn)襟y臼鋼板內(nèi)固定(實驗組),(2)L-形鋼板內(nèi)固定(L-形鋼板組),(3)T-形鋼板內(nèi)固定(T-形鋼板組),(4)H-形鋼板內(nèi)固定(H-形鋼板組),(5)多向鈦鋼板內(nèi)固定(多向鈦鋼板組),及(6)髂恥上緣長螺釘內(nèi)固定(髂恥上緣長螺釘組)。生物力學(xué)特性采用以下4個因素來評估:各內(nèi)固定在300 N載荷下的位移、使骨折位移2 mm和3 mm時所加載的力、及剛度。結(jié)果:實驗組,在300 N載荷下骨折平均位移(2.3±0.2)mm、使骨折位移2 mm和3 mm時所加載的力分別為(220.2±49.0)N和(327.9±52.3)N、平均剛度為(119.9±21.1)N/mm。L-形鋼板組,在300 N載荷下骨折平均位移(3.0±0.5)mm、使骨折位移2 mm和3 mm時所加載的力分別為(199.8±34.9)N和(310.0±46.0)N、平均剛度為(100.8±15.5)N/mm。T-形鋼板組,在300 N載荷下骨折平均位移(3.4±0.2)mm、使骨折位移2 mm和3 mm時所加載的力分別為(138.4±20.7)N和(284.4±61.0)N、平均剛度為(78.5±12.6)N/mm。H-形鋼板組,在300N載荷下骨折平均位移(3.2±0.7)mm、使骨折位移2 mm和3 mm時所加載的力分別為(206.6±56.4)N和(306.3±48.1)N、平均剛度為(100.4±24.3)N/mm。多向鈦鋼板組,在300 N載荷下骨折平均位移(1.7±0.3)mm、使骨折位移2 mm和3 mm時所加載的力分別為(395.2±107.7)N和(645.7±77.8)N、平均剛度為(192.1±43.1)N/mm。髂恥上緣長螺釘組,在300 N載荷下骨折平均位移(1.7±0.3)mm、使骨折位移2 mm和3 mm時所加載的力分別為(395.2±107.7)N和(645.7±77.8)N、平均剛度為(187.0±33.8)N/mm。在6組內(nèi)固定中,比較使骨折位移2 mm和3 mm時所加載的力,發(fā)現(xiàn)多向鈦鋼板組和髂恥上緣長螺釘組顯著高于其他4組(P0.05),而多向鈦鋼板組和髂恥上緣長螺釘組之間差異無統(tǒng)計學(xué)意義(P0.05);在剩下的4組中,T-形鋼板組使骨折位移2 mm時的力,顯著小于其他三組(P0.05),而其他三組之間差異無統(tǒng)計學(xué)意義(P0.05),但使骨折位移3 mm時的力,4組的差異無統(tǒng)計學(xué)意義(P0.05)。6組內(nèi)固定中,比較當(dāng)標(biāo)本加載300 N載荷時的位移,發(fā)現(xiàn)相比其他組,髂恥上緣長螺釘組和多向鈦鋼板組位移最小(P0.05),實驗組位移第二小(P0.05);而髂恥上緣長螺釘組和多向鈦鋼板組之間位移差異無統(tǒng)計學(xué)意義(P0.05),同時L-形鋼板、T-形鋼板、H-形鋼板之間位移差異也無統(tǒng)計學(xué)意義(P0.05)。比較6種內(nèi)固定剛度,發(fā)現(xiàn)髂恥上緣長螺釘組和多向鈦鋼板組剛度顯著高于其他內(nèi)固定組(P0.05),實驗組剛度顯著高于剩下的3組(P0.05),而T-形鋼板組剛度最小(P0.05)。結(jié)論:在固定髖臼方形區(qū)骨折方面,髂恥上緣長螺釘和多向鈦鋼板具有最好的生物力學(xué)特性;單向鉸鏈?zhǔn)襟y臼鋼板相比L-形鋼板、T-形鋼板、H-形鋼板具有較好的生物力學(xué)特性。
[Abstract]:Part 1: epidemiological and clinical imaging features of acetabular fractures in the elderly: analysis of the epidemiological characteristics of acetabular fractures in the elderly, and comparison of the clinical and imaging features of the elderly and young acetabular fractures. Methods: a retrospective analysis of the clinical management of acetabular fractures in First Hospital Affiliated to Suzhou University from January 1990 to December 2013. Material. According to a certain inclusion and exclusion criteria, a total of 637 (637 hip) acetabular fractures were analyzed. According to the age of the patients, the patients were divided into elderly acetabular fractures (older than or equal to 60 years old) and young acetabular fractures (age less than 60 years old). The distribution of other injuries in the young acetabular fractures, the characteristics of the injury mechanism of the old and young acetabular fractures, the distribution characteristics of the old and young acetabular fractures, and the imaging characteristics of the old and young acetabular fractures. Results: in 637 cases of acetabular fractures, 133 cases of acetabular fracture, 504 cases of young acetabular fractures, from 1990 to 2013, The incidence of acetabular fractures in the aged increased significantly from 6.7% in 1990 to 40% in 2013 (p=0.021); the annual average age of acetabular fractures increased from (40.9 + 9.2) years (40.9 + 9.2) to 2013 (49.8 + 15.6) years (p=0.045); from early (1990~2000 years) to late (2001~2013 years), the incidence of acetabular fractures in the elderly increased by 1.7 times (14.1%vs.24.1%, P=0.004). The incidence of acetabular fracture with other injuries in the elderly was significantly lower than that of young acetabular fractures (27.1%vs.48.8%, p=0.000). The common mechanism for the injury of the aged acetabular fractures was the same level of fall (that is, a standing height fall), accounting for 36.1%, while only 0.2% (p=0.000) was caused by the fall of the young acetabular fracture (8.3%vs.1). The anterior wall fracture in the elderly (8.3%vs.1 .0%, p=0.000), the incidence of anterior column fracture (10.5%vs.4.8%, p=0.013), anterior column + posterior half transverse fracture (3.8%vs.0.4%, p=0.005) was significantly higher than that of young patients. The incidence of posterior dislocation of acetabular fracture in elderly patients was significantly lower than that of young patients (16.5%vs.31.9%, p=0.000), and other such as square fracture (23.3%vs.3.2%, p=0.000), seagull sign (21.1%vs.0.8%). P=0.000), the incidence of 21.8%vs.10.3% (p=0.000), femoral head injury (13.5%vs.4.6%, p=0.000), comminuted posterior wall fracture (10.5%vs.3.6%, p=0.001), posterior marginal compression fracture (12.0%vs.3.2%, p=0.000) were significantly higher than that of young patients. Conclusion: the proportion of the elderly patients with acetabular fractures and the acetabular bone The age of the fractured patients is on the rise; the incidence of the acetabular fracture with other injuries in the elderly, the mechanism of injury, the type of fracture, and the imaging features are different from those of the young patients. Considering the imaging features of the acetabular fracture in the elderly, the clinical effects are often combined, so the type of fracture and the imaging features of the aged hip fractures should be based on the characteristics of the fracture type and the imaging features. To make the best medical decision in order to get a satisfactory clinical effect. In view of the fall injury is the most common cause of the acetabular fracture in the elderly, we should take special measures to prevent the fall of the elderly in the daily life. The second part of the analysis of the factors affecting the curative effect of the aged acetabular fracture: open reduction and internal fixation There is still debate about the clinical efficacy of the treatment of the aged displaced acetabular fractures, and the prognosis is poor if the elderly acetabular fractures are associated with some imaging features. However, it is not clear what is the key factor in determining the postoperative effect of acetabular fractures in the elderly. Therefore, this study aims at many factors, through statistical credits. The key factors affecting the prognosis of senile acetabular fractures were determined by open reduction and internal fixation. Methods: from May 1990 to June 2010, the elderly patients with displaced acetabular fractures treated with open reduction and internal fixation were analyzed retrospectively. A total of 86 patients (86 hips) were included in the final analysis according to a certain inclusion and exclusion criteria, of which 71 were male. 15 women, 15 years old, average age (67.7 + 7.3) years old. The quality of fracture reduction was Matta's standard after operation. The modified Merle D 'Aubigne-Postel score was used to evaluate the clinical function. According to previous reports, the quality of fracture reduction and the following 6 imaging features were included in the analysis of the related factors, including the square fracture, Mi, posterior dislocation of the hip, femoral head injury, comminuted posterior wall fracture and compression fracture of the posterior wall. Results: the duration of follow-up was 2~198 months, averaging 39 months. At the last follow-up, the acetabular fracture combined with the above 6 imaging features, the average improved Merle D 'Aubigne-Postel score was (14.4 + 3.1), and none of these imaging features, The average improved Merle D 'Aubigne-Postel score was (17.2 + 1.6) scores. In the last follow-up, 86 patients with fracture anatomic reduction, poor reduction and poor reduction, the average improved Merle D' Aubigne-Postel score was (16.8 + 2.4), (14.5 + 2.3) and (11.3 + 1.4). Multivariate stepwise regression model analysis showed the quality of fracture reduction (t=-10.45 P=0.000), comminuted posterior wall fracture (t=-2.74, p=0.008) and femoral head injury (t=-3.51, p=0.000) are the key factors affecting the prognosis of senile acetabular fractures with open reduction and internal fixation. Conclusion: anterior acetabular fracture combined with posterior wall comminuted fracture and femoral head injury are independent outcome of open reduction and internal fixation in the treatment of the prognosis of acetabular fractures in the elderly The quality of postoperative fracture reduction is an independent predictor of the clinical efficacy of open reduction and internal fixation for the treatment of acetabular fractures in the elderly. If the postoperative fracture can be anatomic reduction, the prognosis of the patients can be predicted satisfactorily. The development of a new type of internal fixator for the third part of the acetabular area fracture and a comparative study of Biomechanics The objective of this study is to assess the biomechanical properties of a new type of internal fixator for the treatment of a square fracture of the acetabulum. The biomechanical properties of the other 5 kinds of internal fixers with square fracture were compared. Methods: Ten semi pelvic specimens of fourth generations of artificial pelvis were taken and a simple square fracture model was made. The half pelvis was fixed on the special fixture so that the level of the acetabular opening was upward and placed in the double axis electron of E10000. On the mechanical mechanical testing machine, the biomechanical properties of six kinds of internal fixation for the treatment of the square fracture of the acetabulum were tested in order: (1) the unidirectional hinge type acetabular plate internal fixation (experimental group), (2) L- shaped plate internal fixation (L- shaped plate group), (3) T- shaped plate internal fixation (T- shaped plate group), (4) H- shaped plate internal fixation (H- shaped plate group), and (5) multidirectional titanium plate Internal fixation (multiplate plate group) and (6) long iliac superior margin screw internal fixation (long iliac superior screw group). Biomechanical properties were assessed by the following 4 factors: displacement of internal fixation under 300 N load, force and stiffness of fracture displacement at 2 mm and 3 mm. Results: experimental group, the average displacement of fracture under 300 N load (2.3 + 0.2) Mm, the forces loaded on the fracture displacement 2 mm and 3 mm were respectively (220.2 + 49) N and (327.9 + 52.3) N, and the average stiffness was (119.9 + 21.1) N/mm.L- shaped steel plate group. The average displacement of the fracture was 3 + 0.5 mm under the load of 300 N, which made the fracture displacement 2 mm and 3 mm loaded as (199.8) N and (52.3) N. The average displacement of fracture was (3.4 + 0.2) mm under the load of 300 N, and the forces loaded at 2 mm and 3 mm were (138.4 + 20.7) N and (284.4 + 61) N respectively, and the average stiffness was (78.5 + 12.6) N/mm.H- shaped plate group. The average displacement of fracture was (3.2 + 0.7) mm under 300N load (3.2 + 0.7), which made the fracture displacement mm and mm. 206.6 + 56.4) N and (306.3 + 48.1) N, the average stiffness was (100.4 + 24.3) N/mm. multidirectional titanium plate group. The average displacement of fracture was (1.7 + 0.3) mm under 300 N load, and the force of the fracture displacement 2 mm and 3 mm was (395.2 + 107.7) N and (645.7 + 24.3) N respectively. The average stiffness was (mean) N/mm. iliac upper edge long screw group, and the fracture was fractured under N load. The average displacement (1.7 + 0.3) mm made the load of fracture displacement 2 mm and 3 mm respectively (395.2 + 107.7) N and (645.7 + 77.8) N respectively, and the average stiffness was (187 + 33.8) N/mm. in group 6, and the forces loaded during the fracture displacement 2 mm and 3 mm were compared, and the multidirectional titanium plate group and the iliac superior margin screw group were significantly higher than those of other groups (P0.05). There was no significant difference between the multidirectional titanium plate group and the long iliac superior margin screw group (P0.05). In the remaining 4 groups, the T- shaped plate group made the fracture displacement of 2 mM significantly less than the other three groups (P0.05), but the difference between the other three groups was not statistically significant (P0.05), but there was no statistical difference between the 4 groups when the fracture displacement was 3 mm (P0.0 5) in the internal fixation of group.6, the displacement of the specimens loaded with 300 N load was compared. It was found that the displacement of the long iliac superior margin screw group and the multidirectional titanium plate group was the least (P0.05), and the displacement of the experimental group was the second little (P0.05), while the difference of the displacement between the long screw group of the iliac upper edge and the multidirectional titanium plate group was not statistically significant (P0.05), and the L- shaped steel plate and T- shape were also found. The displacement difference between the steel plate and the H- shaped plate was not statistically significant (P0.05). Comparing the 6 internal fixation stiffness, it was found that the stiffness of the long iliac superior margin screw group and the multidirectional titanium plate group was significantly higher than the other internal fixation group (P0.05). The stiffness of the experimental group was significantly higher than the remaining 3 groups (P0.05), but the stiffness of the T- plate group was minimum (P0.05). Conclusion: in the fixed acetabular square. In the area of fracture, the long iliac upper edge screw and the multidirectional titanium plate have the best biomechanical properties, and the unidirectional hinged acetabular plate has better biomechanical properties than the L- steel plate, the T- steel plate and the H- shaped plate.

【學(xué)位授予單位】：蘇州大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2015
【分類號】：R687.3

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