發(fā)布時間：2018-06-09 14:45

  本文選題：膝關節(jié) + 運動學　； 參考：《第三軍醫(yī)大學》2015年博士論文

【摘要】：研究背景膝關節(jié)的運動學是理解膝關節(jié)的生理功能以及病理改變的基礎科學。與生物力學一樣,它也是諸多臨床手術(shù)的基礎,如全膝關節(jié)置換術(shù)(total knee arthroplasty,TKA)、前交叉韌帶重建術(shù)等。在過去的一百多年中,有諸多的解剖學、生物力學的學者及臨床醫(yī)生對膝關節(jié)的運動學進行了廣泛的研究。由于運動本身的復雜性,既往學者建立了多種理論和模型來對膝關節(jié)的運動進行解釋和描述。在這些工作的基礎上,現(xiàn)代的膝關節(jié)手術(shù)技術(shù)有了飛速發(fā)展。其中最典型的是TKA。早期的TKA手術(shù)具有較高的失敗率和較短的假體壽命,而現(xiàn)代的TKA盡管仍存在一些亟待解決的問題,但成功率已經(jīng)大幅提高,成為被學界廣范認可的治療終末期骨性關節(jié)炎的金標準。盡管如此,在膝關節(jié)運動學的有關研究中,仍有一些問題尚未被完全闡明。其中,兩個重要的問題是膝關節(jié)的生理對位和屈伸軸線(flexion-extension axis,FEA)的測定。對于前者,既往的研究者對冠狀面和矢狀面的對位問題已較為明確。比如在冠狀面,學者們通常認為在理想狀態(tài)下從股骨頭中心到踝關節(jié)中心走行的下肢力線應經(jīng)過膝關節(jié)的中心。然而對于膝關節(jié)在橫斷面的對位,既往的研究則較為匱乏,并且缺少一致性的結(jié)論。這種情況很大程度上是由于膝關節(jié)的橫斷面對位容易受到膝關節(jié)運動的影響;由于脛骨與股骨的相對旋轉(zhuǎn)是伴隨著關節(jié)屈伸而存在的固有運動,膝關節(jié)橫斷面的對位也是隨著屈膝角度實時變化的。從生物力學角度來說,這種在功能活動中表現(xiàn)出的動態(tài)對位關系對于膝關節(jié)的生理功能(如髕股關節(jié)功能等)以及臨床診療(如TKA中脛骨假體的旋轉(zhuǎn)對位等)應具有更重要的意義。在既往有限的針對膝關節(jié)橫斷面對位關系的研究中,絕大多數(shù)考察的是伸直位時靜態(tài)的對位關系,而對基于運動學的動態(tài)對位則鮮有涉及。對于膝關節(jié)的FEA,在過去的幾十年中學者們已從很多不同的角度對其進行了研究。早期的學者認為膝關節(jié)的FEA不是固定的,而是隨著屈膝角度的變化在股骨遠端按照一定的規(guī)律浮動。比如針對二維運動的“瞬時旋轉(zhuǎn)中心”和針對三維運動的“瞬時旋轉(zhuǎn)軸”的概念。這種非固定的旋轉(zhuǎn)軸心的數(shù)學表達非常復雜,不利于臨床醫(yī)生掌握和應用。近年來的研究者傾向于認為膝關節(jié)是圍繞著兩條固定的軸線運動:圍繞著fea進行屈伸,同時圍繞著另一條豎直軸線(longitudinalaxis,lra)進行內(nèi)外旋。該模型簡化了運動的表述形式,同時可以將固定化的功能軸線和解剖軸線進行關聯(lián)。fea的位置和方向?qū)εR床具有重要參考價值,比如tka中假體的設計和安裝等。因此對其進行準確的解剖定位十分重要。然而,目前學界對于fea的解剖位置仍然存在爭議。既往的學者認為股骨的髁上軸(transepicondylaraxis,tea)與fea具有一致性。然而這一結(jié)論被最近的實驗所質(zhì)疑。學者們發(fā)現(xiàn)tea的方向在屈膝中會發(fā)生改變,因此不符合固定旋轉(zhuǎn)軸的要求;另一些學者主張連接股骨后髁中心的幾何中心軸(cylinderaxis,ca)才是與fea最接近的解剖軸線,但對于該結(jié)論目前仍需更多的實驗來驗證。此外既往對于fea的計算方法也存在一定缺點。它要求先通過反復的膝關節(jié)內(nèi)外旋實驗來定位lra,再根據(jù)lra的位置測量fea。這種方法僅適合膝關節(jié)標本的體外測量實驗,而難于在活體運動學采集中應用。因此開發(fā)一種新的計算fea的方法也十分必要。本研究的目標是,首先建立一套基于雙平面x線攝影結(jié)合3d模型與2d影像配準技術(shù)的膝關節(jié)運動學檢測方法,并對其準確性進行驗證。在此基礎上,采集正常膝關節(jié)在體負重情況下的運動學數(shù)據(jù),分析股骨與脛骨在橫斷面上動態(tài)的對位關系。對此我們定義了一個股骨在運動過程中綜合性的前-后方向,并將其和多條脛骨的解剖參考軸線進行對比。第三個目標是建立一種新的方法對fea進行計算,隨后將fea同tea和ca兩條解剖軸線的位置進行對比,判斷哪一條可以更好地作為fea的解剖替代。這些功能與解剖的關系的建立將為膝關節(jié)的基礎研究和臨床提供有意義的參考。研究方法1、雙平面x線攝影與三維模型-二維影像配準技術(shù)的建立及驗證研究。我們通過一臺固定式數(shù)字x光機(digitalradiography,dr)與一臺移動式dr組建雙平面x線影像采集系統(tǒng)。兩臺dr在場地中互相垂直安放,x線束相交的區(qū)域為有效成像區(qū)域。受檢者可以在成像區(qū)域中完成膝關節(jié)的負重屈伸運動。在每一個屈膝的位置,兩臺dr可以同時從兩個角度捕捉目標膝關節(jié)的x線影像。隨后通過ct掃描及三維重建獲取目標膝關節(jié)的幾何實體模型。三維模型與二維模型的配準在現(xiàn)有的計算機三維建模軟件中完成。配準的虛擬環(huán)境嚴格按照運動學采集時實驗室的物理環(huán)境的比例設置。配準的過程依靠手動完成,采用平移和旋轉(zhuǎn)的方式對幾何模型的空間位置進行調(diào)整,以模型輪廓和雙平面影像輪廓達到完美匹配為目標。在對多個屈膝位置的影像進行配準之后,通過對模型的整合即可獲取膝關節(jié)連續(xù)運動的軌跡。對于該方法的驗證,我們采用尸體標本進行。首先將膝關節(jié)標本固定在某個屈膝角度,并進行ct掃描和三維重建,獲取的模型作為標準參照。隨后采用雙平面x線攝影與三維模型-二維影像配準的方法對同一標本進行檢測,將配準的模型與上述標準參照進行對比,從而對系統(tǒng)誤差進行評估。2、膝關節(jié)橫斷面的動態(tài)旋轉(zhuǎn)對位研究利用如前述所建立的運動學采集方法,我們采集了20例健康成人志愿者單側(cè)膝關節(jié)的運動學數(shù)據(jù)。對于每個受試者,分別采集其在單腿弓步屈膝運動下0°、15°、30°、60°、90°和120°時的運動學數(shù)據(jù)。在0°的模型中,確定一條股骨的前后軸線(femoralanteroposterioraxis,faa),并追蹤該軸線的方向在上述屈膝位置中的變化。在此基礎之上,計算出一個綜合性的方向,即動態(tài)股骨前后軸線(femoralanteroposterioraxisofmotion,faam),該方向?qū)⑴c各屈膝角度下的faa保持最小的誤差平方和。我們認為faam是一條代表了在整個動態(tài)屈膝過程中股骨綜合性的前-后方向的軸線。在此基礎上,faam與數(shù)條定義在脛骨上的解剖參考軸線的位置進行比對,從而建立解剖-功能的關系。對于這些軸線,測量它們與faam間角度偏差。此外,還著重考察了faam與脛骨結(jié)節(jié)間的位置關系。3、膝關節(jié)的屈伸軸線的研究基于上一部分研究中建立的20例樣本的膝關節(jié)運動學數(shù)據(jù)庫,我們開發(fā)了一個新算法對fea進行計算。簡而言之,我們首先將股骨的三維模型轉(zhuǎn)化為表面點云數(shù)據(jù)集;獲取并追蹤點云中每個點的初始坐標值以及其在整個屈膝過程中的變化,并計算坐標值在豎直方向的變化累積值。隨后在點云集中,篩選出兩個累積變化值最小的點,分別位于股骨內(nèi)髁和股骨外髁表面。進而我們將連接上述兩點的直線定義為fea。該算法的基本思想是,圓形剛體在平面上滾動時,其旋轉(zhuǎn)中心應始終與平面間保持相對恒定的距離,而旋轉(zhuǎn)中心以外的點則會出現(xiàn)較大幅度的上下起伏。在此基礎之上,我們比較了fea與股骨遠端兩條常用軸線間的位置關系;這兩條軸線包括tea和ca。測量包括fea、tea與ca三者之間的在平面以及三維空間的角度差異,以及三條軸線位于股骨髁表面的端點間的距離�；诖�,tea與fea以及ca與fea間的匹配程度得以進行直接的比較。結(jié)果1、本研究所建立的雙平面x線攝影與三維模型-二維影像配準技術(shù)可以有效地對膝關節(jié)負重狀態(tài)下的運動學進行檢測,并保持較高精度。根據(jù)尸體驗證實驗的結(jié)果,該方法在前后、內(nèi)外以及遠近方向上平移自由度的平均偏差分別為0.80mm,0.81mm和0.70mm;在冠狀面、矢狀面以及橫斷面三個平面上旋轉(zhuǎn)自由度的平均偏差分別為0.79°,0.88°和1.06°。2、使用上述建立的方法成功獲取了所有參檢志愿者的運動學信息。faa在從伸直位到屈膝的過程中表現(xiàn)出外旋的趨勢,在屈膝90°時達到最大(11.6°)。在參與測量的解剖軸線當中,沒有任何一條可以與faam完全匹配。它們與faam的角度差異從外旋11.0°到內(nèi)旋9.7°。然而,當faam經(jīng)過脛骨平臺中心時,其傾向于與脛骨結(jié)節(jié)相交于其內(nèi)側(cè)1/3部分,即內(nèi)側(cè)緣與中內(nèi)1/3點之間。3、在所有樣本中均成功計算出了fea。其從股骨后髁的中心區(qū)域穿過。在參與對比的兩條解剖軸線中(tea與ca),fea與tea在三維空間以及橫斷面的角度差異高于fea與ca(三維:3.45°vs1.98°,p0.001;橫斷面:2.72°vs1.19°,p=0.002),但兩者在冠狀面則沒有顯著差異(1.61°vs0.83°,p=0.076)。關于三條軸線在股骨髁表面的端點,fea與tea在內(nèi)側(cè)面的端點間的距離顯著高于fea與ca(6.7mmvs1.9mm,p0.001);而在外側(cè)面兩者沒有顯著差異(3.2mmvs2.0m,p=0.16)。結(jié)論1、本研究所建立的雙平面x線攝影與三維模型-二維影像配準技術(shù),是一個檢測膝關節(jié)在體負重狀態(tài)下運動學的有效方法。其具有較高的精度,在平移和旋轉(zhuǎn)自由度上的偏差可以分別控制在1mm以下和1°左右。與其他的運動學檢測手段,比如光學運動采集、mri以及x線立體攝影測量等相比,我們所建立的方法在易用性、準確性和可行性間達到了一個較好的平衡,可以滿足后續(xù)實驗的需要。2、目前在膝關節(jié)中較為常用的幾條解剖參考軸線并不能準確地指示膝關節(jié)在橫斷面上的動態(tài)對位。與之相比,后者與脛骨結(jié)節(jié)的中內(nèi)三分之一部分可能存在更多的相關性。本研究所發(fā)現(xiàn)的這種功能與解剖的關系可幫助我們更好地理解膝關節(jié)的生理功能。此外該發(fā)現(xiàn)也可能為tka提供一定的理論支持。針對目前臨床所使用的利用脛骨結(jié)節(jié)中內(nèi)1/3作為脛骨假體旋轉(zhuǎn)對位的解剖參考標志的方法,本研究為其提供了一定的實驗依據(jù)。3、我們建立的新方法可以基于連續(xù)的膝關節(jié)運動學數(shù)據(jù)對fea進行計算。膝關節(jié)的fea并不與tea相吻合,與之相比,它與ca在空間上更加接近。因此ca可能是fea的一個更好的解剖替代。本研究所發(fā)現(xiàn)的這種功能與解剖的關系可幫助我們更好地理解膝關節(jié)的生理功能。由于CA更接近于FEA,它可能具有更大的臨床應用價值。
[Abstract]:The kinematics of the knee joint is the basic science to understand the physiological functions and pathological changes of the knee joint. Like biomechanics, it is also the basis of many clinical operations, such as total knee replacement (total knee arthroplasty, TKA), anterior cruciate ligament reconstruction, and so on. In the past more than 100 years, there are many anatomy and organisms. Mechanical scholars and clinicians have conducted extensive research on the kinematics of the knee joint. Due to the complexity of the motion itself, a variety of theories and models have been established to explain and describe the motion of the knee joint. On the basis of these work, modern knee surgery techniques have developed rapidly. The most typical of these is TKA. Early TKA surgery has a high failure rate and a shorter prosthesis life, while the modern TKA still has some problems to be solved, but the success rate has been greatly improved, which has become the golden standard for the treatment of end-stage osteoarthritis of the end of the study. The two important questions are the physiological alignment of the knee and the flexion-extension axis (FEA). For the former, the former researchers have been more explicit about the coronal and sagittal facet. For example, on the coronal plane, the learners generally believe that the femoral head is from the center of the femoral head to the center of the femoral head. In the center of the ankle joint, the force line of the lower extremities should go through the center of the knee joint. However, the previous study is relatively scarce and lacks consistency in the cross section of the knee joint. This is largely due to the vulnerability of the knee joint to the knee joint movement; the relative of the tibia and the femur. Rotation is an inherent movement associated with joint flexion and extension, and the cross section of the knee is also changed with the angle of knee flexion. From the biomechanical point of view, the dynamic alignment of the functional activities in the functional activities (such as patellar joint function, etc.) and clinical diagnosis (such as tibial sham in TKA) In the previous limited study of the position relationship of the knee joint transection, the overwhelming majority of the investigation is the static alignment at the straight position, while the dynamic alignment based on the kinematics is rarely involved. For the FEA of the knee joint, many scholars have gone from the past few decades. The early scholars believe that the FEA of the knee joint is not fixed, but is fluctuated at the distal femur with a variation of the angle of the knee. For example, the concept of "instantaneous rotation center" for two-dimensional motion and the concept of "instantaneous axis of rotation" for three-dimensional motion. This non fixed rotating axis. The mathematical expression is very complex and is not conducive to the mastery and application of the clinicians. In recent years, researchers tend to think that the knee joint is around two fixed axes motion: the flexion and extension around the FEA and the internal and external rotation around another vertical axis (longitudinalaxis, LRA). The location and direction of the.Fea associated with the immobilized functional axis and the anatomical axis are of important reference value to the clinic, such as the design and installation of the prosthesis in the TKA. Therefore, it is important to make an accurate anatomical location for it. However, there is still a dispute over the anatomical position of FEA. The transepicondylaraxis (tea) is consistent with FEA. However, this conclusion has been questioned by recent experiments. Scholars have found that the direction of tea will change in the knee and therefore does not meet the requirements of the fixed axis of rotation; other scholars argue that the geometric center axis (cylinderaxis, CA) connecting the posterior condyle center of the femur (cylinderaxis, CA) is the closest to FEA The anatomic axis, however, still needs more experiments to verify this conclusion. In addition, there are some shortcomings in the previous calculation method for FEA. It is required to locate LRA through repeated internal and external rotation experiments of the knee joint, and then measure fea. according to the position of LRA only suitable for the test of the knee joint specimens in vitro, but difficult to live in. It is also necessary to develop a new method of calculating FEA. The aim of this study is to establish a set of knee joint kinematics detection methods based on double plane X-ray photography combined with 3D model and 2D image registration technique, and to verify its accuracy. On this basis, the normal knee joint is collected in body negative. The kinematic data under heavy circumstances analysis the dynamic alignment of the femur and tibia on the cross section. We define a comprehensive front and back direction of a femur during the movement and compare it with the anatomical reference axis of the multiple tibia. The third goal is to establish a new method to calculate the FEA, and then the FEA Comparison with the position of the two anatomical axes of tea and Ca to determine which one can be a better substitute for the anatomy of FEA. The establishment of the relationship between these functions and anatomy will provide a meaningful reference for the basic research and clinic of the knee joint. Method 1, biplane X-ray photography and three-dimensional model - two-dimensional image registration technology We set up a dual plane X-ray image acquisition system with a fixed digital X-ray machine (digitalradiography, Dr) and a mobile Dr. Two sets of Dr are placed vertically in the site. The area of the X-ray beam intersection is an effective imaging area. The receiver can perform the flexion and extension movement of the knee joint in the imaging area. The position of the knee, two DR can capture the X-ray images of the target knee joint from two angles. Then, the geometric entity model of the target knee joint is obtained by CT scanning and three-dimensional reconstruction. The registration of the three-dimensional model and the two-dimensional model is completed in the existing computer 3D modeling software. The virtual environment of registration is strictly according to the kinematic acquisition. The proportion of the physical environment in the laboratory is set. The registration process relies on manual completion. The spatial position of the geometric model is adjusted by translation and rotation. The model contour and the biplane image contour are matched perfectly as the target. After the registration of the images of multiple knees, the integration of the model can be obtained. To verify the continuous motion of the knee joint, we use the cadaver specimens to verify the method. First, the specimens of the knee joint are fixed on a knee flexion angle, and the CT scan and three-dimensional reconstruction are used as the standard reference. Then the same specimen is used by the double plane X-ray photography and the three-dimensional model - two-dimensional image registration method. By comparing the registration model with the above standard reference, the system error is evaluated by.2. The dynamic rotation of the knee joint cross section is used to collect the kinematic data of the Dan Cexi joints of 20 healthy adult volunteers. The kinematic data are collected at 0, 15, 30, 60, 90 and 120 degrees under the single leg knee flexion. In the 0 degree model, the axis of the femur (femoralanteroposterioraxis, FAA) is determined and the direction of the axis changes in the position of the knee flexion. On this basis, a comprehensive direction is calculated. The axis of the femur (femoralanteroposterioraxisofmotion, faam), which will keep the minimum square sum of the error of the FAA under each knee angle. We think that faam is an axis that represents the integrated front and rear direction of the femur during the entire dynamic knee flexion. On this basis, faam and several sections define the anatomical parameters on the tibia. The position of the axis is compared, and the relationship between the anatomy and function is established. For these axes, the angle deviations between them and faam are measured. In addition, the relationship between the faam and the tibial tubercle is also focused on the relationship between the position of the tibial tubercle.3, the flexion and extension axis of the knee joint, which is based on the kinematics database of the knee joint of 20 cases established in the last part of the study. We have developed a new algorithm to calculate the FEA. In short, we first transform the three-dimensional model of the femur into a surface point cloud data set; get and track the initial coordinates of each point in the point cloud and the changes in the whole knee flexion, and calculate the cumulative value of the coordinate values in the vertical direction. Then, in the point cloud, the sieves are concentrated. Two points with the smallest cumulative change values are selected at the inner condyle of the femur and the surface of the outer condyle of the femur respectively. Then we define the straight line connecting the two points as fea.. The basic idea of the algorithm is that when the circular rigid body rolls on the plane, the rotation center should always keep the constant distance from the plane, and the point outside the rotation center. On the basis of this, we compare the position relationship between FEA and the two common axis of the distal femur; the two axes include the tea and ca. measurements of the differences in the plane and the three-dimensional space between the FEA, the tea and the CA three, and the distance between the three axes at the surface of the femur condyle. Based on this, the matching degree between tea and FEA and Ca and FEA can be directly compared. Results 1, the biplane X-ray photography and three-dimensional image registration technique established by this study can detect the kinematics of the knee joint effectively and maintain high accuracy. The method is based on the results of the corpse verification experiment. The average deviations of the translational degrees of freedom were 0.80mm, 0.81mm and 0.70mm, respectively, and the average deviations of the rotational degrees of freedom on the coronal, sagittal and cross sections of the three planes were 0.79, 0.88 and 1.06.2 respectively. The kinematic information.Fa of all the volunteers was successfully obtained by the above method. A shows a trend of external rotation during the extension of the position to the knee, reaching the maximum (11.6 degrees) at 90 degrees. No one in the anatomic axis participating in the measurement can be fully matched with the faam. The difference from the angle of the faam from the outer rotation 11 degrees to the internal rotation 9.7 degrees. However, when faam passes through the tibial plateau center, it tends to be with the tibia. The bone nodules intersected in the medial 1/3 part, that is,.3 between the medial margin and the middle 1/3 point. In all the samples, fea. has been successfully calculated from the central region of the posterior femoral condyle. In the two dissection axes (tea and CA), the differences between FEA and tea in the three-dimensional space and the transverse section are higher than FEA and Ca (3.45 degrees vs1.98, P0). .001; cross section: 2.72 degree vs1.19, p=0.002), but there is no significant difference between the two on the coronal plane (1.61 degrees vs0.83, p=0.076). The distance between the three axes on the surface of the femoral condyle and the distance between FEA and tea at the medial surface is significantly higher than that of FEA and Ca (6.7mmvs1.9mm, p0.001), but there is no significant difference between the outer sides (3.2mmvs2.0m,). 1, the biplane X-ray photography and three-dimensional image registration technique established by this study are an effective method to detect the kinematics of the knee joint under the body load condition. It has high accuracy. The deviation of the translational and rotational degrees of freedom can be controlled under 1mm and 1 degrees respectively. For example, optical motion acquisition, MRI and X-ray stereopotrometry, we have achieved a better balance between the usability, accuracy and feasibility of the method, which can meet the needs of.2 in the follow-up experiment. At present, several commonly used axes in the knee joint can not accurately indicate the knee joint in the cross section. In contrast, the latter may have more relevance to the 1/3 parts of the tibial tubercle. The relationship between this function and the anatomy can help us to better understand the physiological functions of the knee joint. Moreover, the discovery may also provide some theoretical support for TKA. This study has provided some evidence for the use of 1/3 in the tibial tubercle as an anatomical reference mark for the rotation of the tibial component.
【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】：R687.3

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