發(fā)布時間：2018-05-31 05:15

  本文選題：股骨干骨折 + 彈性髓內(nèi)釘��； 參考：《第四軍醫(yī)大學(xué)》2017年博士論文

【摘要】：股骨干長螺旋形骨折,即骨折斜面長度大于骨折部位股骨直徑2倍以上的股骨干螺旋形骨折,是一種以長度不穩(wěn)定為主要特點的特殊骨折類型,多由高能暴力引起。隨著社會經(jīng)濟水平提升,兒童出行和各種活動增加,交通事故等高能旋轉(zhuǎn)暴力因素所導(dǎo)致的兒童股骨干長螺旋形骨折發(fā)病率逐年增加,如何治療成為小兒骨科研究和爭論的熱點。得益于手術(shù)方式、固定技術(shù)的突破,使得兒童股骨干骨折的治療不再局限于牽引和石膏固定,從而獲得更加快速可靠的治愈。特別是法國醫(yī)生Metaizeau、Prévot發(fā)明的彈性髓內(nèi)釘技術(shù)(elastic stable intramedullary nailing,ESIN),經(jīng)過近40年來的全球廣泛實踐證明,被公認為治療兒童長骨干骨折的首選治療方式。然而大部分研究認為ESIN方法僅適用于7-14歲兒童的股骨干橫形或短斜形骨折,并不推薦用于長螺旋形這樣的長度不穩(wěn)定型骨折。主要理由有以下兩方面:1.學(xué)齡前兒童骨骼重塑能力強,ESIN技術(shù)相較非手術(shù)治療優(yōu)勢不明顯;2.長螺旋形骨折穩(wěn)定性差、易旋轉(zhuǎn),可能造成更高并發(fā)癥幾率。本課題組認為學(xué)齡前兒童(2-7歲)同樣有著快速康復(fù)的需求,前期本課題組已經(jīng)開展了ESIN治療學(xué)齡前兒童股骨干長螺旋形骨折的臨床探討性試用,初步隨訪結(jié)果證實能獲得良好的臨床效果。但目前國內(nèi)外對該方法治療股骨干長螺旋形骨折置釘方法及穩(wěn)定機制研究較少。研究目的:采用“有限元模擬”、“離體生物力學(xué)實驗”等方法,比較不同彎釘置釘方式對于治療后股骨整體力學(xué)性能的影響,分析ESIN對骨折的固定機制并優(yōu)化置釘方法;通過回顧性病例比較研究,比較ESIN治療兩種類型骨折(長螺旋形骨折vs橫形/短斜形骨折)的臨床療效及并發(fā)癥情況,分析ESIN治療學(xué)齡前兒童股骨干長螺旋形骨折的臨床效果,為該技術(shù)的臨床提供實驗依據(jù)。研究方法:一、兩種不同ESIN彎釘置釘方式治療股骨干長螺旋形骨折的有限元模擬研究。(1)建立股骨長螺旋形骨折數(shù)字模型,與彈性髓內(nèi)釘模型組合后進行網(wǎng)格劃分;(2)采用Abaqus軟件,比較“骨折頂點置釘”和“對稱置釘”在靜力條件和模擬單足站立時的應(yīng)力分布及其特點;(3)采用模擬四點彎曲、旋轉(zhuǎn)、負重等載荷,比較兩種彎釘置釘方法修復(fù)后股骨的抗彎曲、抗旋轉(zhuǎn)及抗壓縮剛度。二、兩種不同ESIN彎釘置釘方式及尾帽治療股骨干長螺旋形骨折的生物力學(xué)研究。(1)標(biāo)準(zhǔn)化股骨干長螺旋形骨折人工股骨24根,隨機分為4個實驗組(n=6),橫形骨折人工股骨3根,設(shè)為對照組;(2)實驗組分別采用“骨折頂點置釘(Vertex Nailing,VN)”、“骨折頂點置釘+尾帽(Vertex Nailing with End Cap,VN+EC)”、“對稱置釘(Symmetrically Nailing,SN)”、“對稱置釘+尾帽(Symmetrically Nailing with End Cap,SN+EC)”固定方式,橫形骨折對照組(Control,Con)進行傳統(tǒng)對稱置釘固定,不加尾帽;(3)采取重復(fù)測量方法,分別進行四點彎曲、扭轉(zhuǎn)、0°及9°壓縮實驗;(4)觀察比較各組間股骨整體的各向抗彎曲剛度、旋轉(zhuǎn)剛度及壓縮剛度。三、ESIN治療學(xué)齡前兒童股骨干兩種類型骨折(長螺旋形骨折vs橫形/短斜行骨折)的臨床比較研究。隨訪本課題組2009年1月至2015年3月采用ESIN治療學(xué)齡前兒童(2-7歲)股骨干長螺旋形骨折21例,并將其與同期收治、采用ESIN治療的59例橫形/短斜行骨折患兒比較,分析兩組病例一般資料、手術(shù)時間、術(shù)中出血、住院費用、骨折愈合時間、負重時間及并發(fā)癥情況。研究結(jié)果:一、通過收斂性檢驗和模型驗證表明所建模型有效。應(yīng)力云圖顯示在負重位時,骨折頂點置釘組較對稱置釘組在皮質(zhì)與彈性髓內(nèi)釘接觸部位提供支撐力更大(7.54MPa vs 5.33 MPa),同時骨折線周圍應(yīng)力分布為均勻,但彈性髓內(nèi)釘釘尾殘存應(yīng)力亦更大(177.29MPa vs 156.22MPa)。有限元模擬加載結(jié)果顯示骨折頂點置釘較對稱置釘能有效提高股骨抗旋轉(zhuǎn)能力,其中內(nèi)旋剛度提高175%(0.22 Nm/°vs 0.08 Nm/°),內(nèi)旋剛度提高92%(0.27 Nm/°vs 0.14 Nm/°),此外骨折頂點置釘抗壓縮性能也具有優(yōu)勢。二、通過體外生物力學(xué)實驗發(fā)現(xiàn),VN+EC組抗反屈、抗內(nèi)翻剛度分別為1.79±0.19 Nm/mm,1.12±0.22 Nm/mm,較其他各組更具優(yōu)勢。骨折頂點置釘在抗旋轉(zhuǎn)方面較對稱置釘組及對照組更強(P0.05),并且加裝尾帽后這一作用進一步增強。9°模擬生理位置和0°軸向壓縮時,EN+EC組治療股骨干長螺旋形骨折能提供與橫形骨折對照組相似的抗壓縮剛度(514.70±32.86vs 504.55±25.22,294.99±23.91 vs298.18±17.33,Nm/mm),并顯著優(yōu)于其他各組。三、本研究納入ESIN治療學(xué)齡前兒童股骨干骨折80例(81肢),其中長螺旋形骨折21例(22肢),平均年齡4.0±1.37歲,平均隨訪17個月(12~30個月)。平均骨折臨床愈合時間7.6±1.4周,平均完全負重時間為12.1±1.6周。全部病例于術(shù)后6~10月骨折愈合后拔除彈性髓內(nèi)釘。隨訪檢查時絕大多數(shù)患兒雙下肢等長,步態(tài)正常,膝關(guān)節(jié)活動正常、無疼痛;8例(長螺旋形骨折3例)出現(xiàn)有針尾皮膚過敏“激惹”現(xiàn)象,拔除髓內(nèi)釘后很快自愈;3例(長螺旋形骨折1例)出現(xiàn)患肢超過1cm過度生長。所有病例均未發(fā)現(xiàn)斷釘退釘、骨髓炎、骨骺損傷、術(shù)后再移位及拔釘后再骨折、骨不連現(xiàn)象。結(jié)論:采用ESIN治療學(xué)齡前兒童股骨長螺旋形骨折,“骨折頂點置釘+尾帽”的固定方式較“對稱置釘”具有更高的抗反屈、抗內(nèi)翻、抗旋轉(zhuǎn)及抗壓縮性能,骨折斷端間的受力更為均勻;臨床研究證實該方法治療患兒的臨床愈合時間、完全負重時間與“橫形/短斜行骨折”患者無顯著差異,是治療學(xué)齡前兒童股骨長螺旋形骨折的安全有效的方法。但由于ESIN并非堅強固定,因此建議術(shù)后早期輔助石膏或支具外固定。
[Abstract]:The long spiral fracture of the femoral shaft, that is, the length of the fracture surface is more than 2 times the femoral diameter of the fracture site, is a special type of fracture, which is mainly characterized by the instability of the length. It is caused by high energy violence. With the social and economic level, the children go out and all kinds of activities increase, traffic accidents and other high energy rotations. The incidence of long spiral fractures of the femur caused by violence has increased year by year. How to treat it has become a hot spot in the research and debate in the pediatric department of orthopedics. The treatment of the fracture of the femoral shaft of children is no longer limited to traction and plaster fixation. It's an elastic intramedullary nail technique (elastic stable intramedullary nailing, ESIN) invented by the French doctor Metaizeau, Pr e VOT. After nearly 40 years of worldwide practice, it has been proved to be the preferred treatment for the treatment of long bone fractures in children. However, most of the studies believe that ESIN is only suitable for the transverse or short femoral shaft of 7-14 year old children. Oblique fractures are not recommended for long spiral fractures such as long helix. The main reasons are the following two aspects: 1. preschool children have strong bone remodeling ability and ESIN technique is not obvious compared with non operative treatment; 2. long spiral fractures are poor in stability, easy to rotate, and may cause higher risk of complications. Children (2-7 years old) also have a rapid recovery demand. In the earlier period, the group has carried out a clinical trial of ESIN for the treatment of long spiral fractures of the femur in preschool children. Preliminary follow-up results confirmed that good clinical results can be obtained. However, the method and stability of the treatment of long spiral fracture of femoral shaft with this method at home and abroad is at home and abroad. The purpose of this study is to compare the effects of different bending nailing methods on the overall mechanical properties of the femur after treatment by using "finite element simulation" and "experiment in vitro biomechanics", to analyze the fixation mechanism of ESIN on the fracture and to optimize the method of nail placement, and to compare the two types of ESIN treatment by comparing the case study. The clinical effect and complication of fracture (vs transverse / short oblique fracture) of long spiral fracture, analysis the clinical effect of ESIN treatment for the long spiral fracture of femur in preschool children and provide experimental basis for this technique. Research method: a finite element model of two different ESIN bending nailing methods for the treatment of long spiral fracture of femur (1) to establish the digital model of long spiral fracture of the femur, and to divide the mesh with the elastic intramedullary nail model. (2) the stress distribution and characteristics of the "fracture apex nail" and "symmetrical nail" are compared with the static condition and the simulation of the single foot. (3) using the simulated four points bending, rotation, load, and other loads, (3) To compare the flexural, anti rotation and compressive stiffness of the femur after two kinds of bending nailing methods, two, two different ESIN bending nailing and tail cap were used to treat the femoral stem long spiral fracture. (1) 24 artificial femoral shaft fractures were standardized into 4 experimental groups (n=6) and transverse fracture artificial femoral shaft. 3 bone was set as control group, and (2) the experimental group adopted "Vertex Nailing, VN", "Vertex Nailing with End Cap, VN+EC", "symmetrical nailing (Symmetrically Nailing, SN)", "symmetrical nailing + tail cap" fixed mode, transverse fracture pair The traditional symmetrical nailing was performed in the group (Control, Con) without tail cap; (3) the compression tests of four points, twists, 0 and 9 degrees were carried out by repeated measurements, and (4) to observe and compare the anisotropic flexural rigidity, rotational stiffness and compression stiffness of the whole femur, three, ESIN for two types of fracture of the femoral shaft of preschool children. A comparative study of vs transverse / short oblique fracture of spiral fracture. 21 cases of long spiral fractures of the femoral shaft of preschool children (2-7 years old) were treated by ESIN from January 2009 to March 2015, and they were compared with 59 cases of transverse / short oblique fractures treated with ESIN in the same period, and the general data of the two groups were analyzed, and the operation time was analyzed. Intraoperative bleeding, hospitalization expenses, fracture healing time, weight negative time and complications. Results: first, the results of convergence test and model verification showed that the model was effective. The stress nephogram showed that the fracture apex group was more supportive than the symmetrical nail group in the contact parts of the cortex and the elastic intramedullary nail (7.54MPa Vs 5.33 MPa), at the same time, the stress distribution around the fracture line is uniform, but the residual stress in the elastic intramedullary nail tail is also greater (177.29MPa vs 156.22MPa). The finite element simulation loading results show that the fracture vertex nailing can effectively improve the anti rotation ability of the femur, of which the internal rotation stiffness is increased by 175% (0.22 Nm/ degree vs 0.08 Nm/ degrees), and the internal rotation stiffness is raised. The high 92% (0.27 Nm/ vs 0.14 Nm/) and the compression resistance of the fracture apex were also superior. Two. Through the biomechanical experiment in vitro, the anti flexion and anti varus stiffness of group VN+EC were 1.79 + 0.19 Nm/mm and 1.12 + 0.22 Nm/mm, respectively. The fracture vertex nail was more than the other groups in the anti rotation group and the control group. Stronger (P0.05), and after the addition of the tail cap further enhanced the.9 degree simulated physiological position and 0 degree axial compression, the EN+EC group was able to provide similar compression stiffness (514.70 + 32.86vs 504.55 + 25.22294.99 + 23.91 vs298.18 + 17.33, Nm/mm) in the treatment of femoral stem long spiral fracture (Nm/mm), and significantly better than the other groups. Three, 80 cases (81 limbs) of femoral shaft fracture of preschool children were treated with ESIN, of which 21 cases of long spiral fracture (22 limbs), average age 4 + 1.37 years, average follow-up for 17 months (12~30 months). The average fracture healing time was 7.6 + 1.4 weeks, and the average full weight was 12.1 + 1.6 weeks. All cases were pulled out after 6~10 month fracture healing. In addition to the elastic intramedullary nail. Most of the children were followed up with equal length of lower limbs, normal gait, normal knee joint movement, no pain, 8 cases (3 cases of long spiral fracture) had the phenomenon of skin allergy "irritability", after pulling out intramedullary nail, 3 cases (1 cases of long spiral fracture) were over growth of the affected limbs. All cases were not. It was found that the treatment of long spiral fracture of femur in preschool children and "nail + tail cap" with ESIN have higher anti flexion, anti internal varus, anti rotation and compression performance and fracture fracture. Clinical studies have proved that this method is a safe and effective method for the treatment of long spiral fractures of the femur in preschool children. However, ESIN is not strong fixed. The paste or the support is fixed outside.
【學(xué)位授予單位】：第四軍醫(yī)大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2017
【分類號】：R726.8
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本文編號：1958429