本文選題：肩峰指數(shù) + 肩峰側(cè)傾角��； 參考：《吉林大學(xué)》2015年博士論文

【摘要】：肩峰形態(tài)的變異一直被認(rèn)為是導(dǎo)致肩袖損傷和盂肱關(guān)節(jié)炎發(fā)生的致病因素之一。諸多學(xué)者通過大量研究，對肩峰形態(tài)的變異以及其與疾病之間聯(lián)系的認(rèn)識(shí)不斷深入。用以描述肩峰形態(tài)變異的影像學(xué)方法應(yīng)運(yùn)而生，其臨床意義也在不斷得到認(rèn)識(shí)。 目前，國內(nèi)外學(xué)者對肩峰指數(shù)、肩峰側(cè)傾角、決定性肩角與肩關(guān)節(jié)疾病相關(guān)聯(lián)系的研究在不斷深入。諸多學(xué)者認(rèn)為這些指標(biāo)可以作為臨床醫(yī)生診斷疾病的輔助臨床參數(shù)。以往的臨床研究，都是研究肩峰某一種形態(tài)的變異與某一種疾病之間的聯(lián)系。但是，如果這些變異同時(shí)出現(xiàn)在同一病人身上，即該患者的肩峰同時(shí)具有兩種甚至更多的特點(diǎn)：比如其肩峰指數(shù)較大，同時(shí)肩峰側(cè)傾角又很小，那么其對于疾病的發(fā)展是協(xié)同作用還是拮抗作用？如果是協(xié)同作用，哪一種變異起到的危害更大些？目前還鮮有報(bào)道。本研究旨在探討肩峰指數(shù)、肩峰側(cè)傾角、決定性肩角與肩關(guān)節(jié)疾病之間的聯(lián)系以及研究這些參數(shù)之間的內(nèi)在規(guī)律，并通過計(jì)算機(jī)數(shù)值仿真分析對其相關(guān)的問題進(jìn)行驗(yàn)證，為治療此類疾病提供部分生物力學(xué)理論基礎(chǔ)。本研究共分為臨床研究和計(jì)算機(jī)數(shù)值仿真分析兩部分。 第一部分：肩峰指數(shù)聯(lián)合肩峰側(cè)傾角的臨床研究。本研究的目的是通過一項(xiàng)臨床研究，來分析肩峰指數(shù)、肩峰側(cè)傾角與肩袖撕裂和肩關(guān)節(jié)急性創(chuàng)傷之間的聯(lián)系。我們利用標(biāo)準(zhǔn)肩關(guān)節(jié)真正前后X像來測量同一患者的肩峰指數(shù)和肩峰側(cè)傾角。肩峰指數(shù)和肩峰側(cè)傾角的測量來自于三組病例：肩關(guān)節(jié)急性創(chuàng)傷組共收錄61名患者，肩袖撕裂組共收錄165名患者，健康對照組共收錄63名患者。研究結(jié)果顯示：肩袖撕裂組的平均肩峰指數(shù)為0.72±0.06，平均肩峰側(cè)傾角76.8°±7.02；急性肩關(guān)節(jié)損傷組平均肩峰指數(shù)0.59±0.05，平均肩峰側(cè)傾角84.4°±7.99；健康對照組肩峰指數(shù)為0.65±0.06；平均肩峰側(cè)傾角80.2°±7.32。各組之間肩峰指數(shù)及肩峰側(cè)傾角具有統(tǒng)計(jì)學(xué)意義（p0.01）。有意思的是，該研究結(jié)果首次發(fā)現(xiàn)，各組的肩峰指數(shù)和肩峰側(cè)傾角均存在一種反比例關(guān)系，即：肩峰向側(cè)方的延展度越大，肩峰向下方的傾斜度也就越大；相反，肩峰向側(cè)方的延展度越小，肩峰向下方的傾斜度也就越小。這一規(guī)律說明，肩峰指數(shù)和肩峰側(cè)傾角在導(dǎo)致肩袖撕裂的過程中起到協(xié)同作用。學(xué)者Nyffeler認(rèn)為小肩峰指數(shù)可能是導(dǎo)致盂肱關(guān)節(jié)炎的重要發(fā)病因素，但是在這部分研究中，我們沒有發(fā)現(xiàn)小肩峰指數(shù)與盂肱關(guān)節(jié)之間存在聯(lián)系。但是我們發(fā)現(xiàn)在因急性肩關(guān)節(jié)創(chuàng)傷的患者中，其平均肩峰指數(shù)明顯小于對照組，因此我們推論：由于肩峰指數(shù)小、肩峰側(cè)傾角較大，從而導(dǎo)致肩峰對其下方肱骨頭的包容度減小，雖然關(guān)節(jié)靈活性好，但是穩(wěn)定性較差；相反，肩峰指數(shù)大、肩峰側(cè)傾角較小，會(huì)增加肩峰對其下方肱骨頭的包容度，因此關(guān)節(jié)穩(wěn)定性增加但靈活性降低。 第二部分：肩峰指數(shù)聯(lián)合肩峰側(cè)傾角及決定性肩角的臨床研究。我們利用標(biāo)準(zhǔn)肩關(guān)節(jié)真正前后X像來同時(shí)測量同一個(gè)患者的肩峰指數(shù)、肩峰側(cè)傾角、決定性肩角。該研究收錄兩組病例：肩袖撕裂患者組共計(jì)105人；健康人群對照組共計(jì)62人。研究結(jié)果顯示：肩袖撕裂患者組的平均決定性肩角為36.2°±4.61；平均肩峰指數(shù)為0.71±0.05；平均肩峰側(cè)傾角為77.2°±5.94。健康對照組的平均決定性肩角為31.7°±5.03；平均肩峰指數(shù)為0.64±0.06；平均肩峰側(cè)傾角為82.0°±7.53。各組的參數(shù)具有統(tǒng)計(jì)學(xué)意義（p0.01）。通過相關(guān)性分析發(fā)現(xiàn)，兩組人群的肩峰形態(tài)存在以下規(guī)律：肩峰指數(shù)與肩峰側(cè)傾角呈反比；肩峰指數(shù)與決定性肩角呈正比。我們稱這一規(guī)律為“肩峰規(guī)律”。由于這一規(guī)律的發(fā)現(xiàn)，我們證明肩峰向側(cè)方的延展度增加，勢必會(huì)導(dǎo)致其向下方的傾斜度增加，在導(dǎo)致肩袖撕裂的病因中二者起到一種協(xié)同作用，但人類的肩峰形態(tài)為何會(huì)發(fā)育成如此，尚不得而知。 第三部分：肩關(guān)節(jié)三維有限元模型的建立，及不同形態(tài)的肩峰撞擊的有限元分析。首先建立肩袖撕裂患者和正常的健康人的兩組肩關(guān)節(jié)模型。利用患者及志愿者的CT數(shù)據(jù)，通過Mimics軟件建立肩胛骨、肱骨的三維幾何模型。由于CT建立的模型其初始位置受到患者的體位的影響，因此，為了準(zhǔn)確測量肩峰指數(shù)、肩峰側(cè)傾角、決定性肩角，將三維模型的位置統(tǒng)一調(diào)整。然后分別在每例模型上測量以上參數(shù)，然后選取一例肩袖撕裂患者的和一例健康人的肩關(guān)節(jié)模型。進(jìn)一步建立岡上肌肌腱、和盂肱關(guān)節(jié)軟骨的三維幾何模型，利用Geomagic Studio優(yōu)化模型后，導(dǎo)入Abaqus軟件，賦予各個(gè)部位材料屬性，隨后在肩胛骨平面做外展撞擊的模擬計(jì)算。從而分析不同肩峰形態(tài)的肩關(guān)節(jié)在肩胛骨平面外展時(shí)，當(dāng)肩峰與其下方的軟組織發(fā)生接觸后肌腱和盂肱關(guān)節(jié)軟骨之間VonMises應(yīng)力及應(yīng)變情況。結(jié)果表明：肩袖撕裂模型外展撞擊后在肌腱與肩峰之間產(chǎn)生的應(yīng)力為172.6MPa（平均12.53MPa），明顯大于健康人模型的42.99MPa（平均5.108MPa），說明肩袖撕裂模型會(huì)在肌腱處產(chǎn)生較明顯的應(yīng)力集中。肩袖撕裂模型外展撞擊后在肱骨頭與肩胛盂軟骨之間產(chǎn)生的應(yīng)力為69.91MPa（平均16.06MPa）大于健康人模型的53.41MPa（平均12.61MPa），該實(shí)驗(yàn)結(jié)果證明在外展撞擊時(shí)肩袖撕裂模型在盂肱關(guān)節(jié)之間產(chǎn)生的應(yīng)力高于正常人模型。 第四部分：前肩峰成形術(shù)的虛擬手術(shù)及有限元分析。目前臨床上治療肩峰下撞擊的一種主要術(shù)式是采用關(guān)節(jié)鏡進(jìn)行前肩峰下成形術(shù)，該手術(shù)通過修改肩峰前外側(cè)下方骨皮質(zhì)的形態(tài)，從而緩解肩峰前部撞擊的發(fā)生。但是該手術(shù)是否可以緩解肩關(guān)節(jié)在肩胛骨平面外展時(shí)所產(chǎn)生的撞擊尚缺少相關(guān)生物力學(xué)研究。選取第三章中的肩袖撕裂模型在Magics軟件中使用多段線切割功能（Polyline Cut）進(jìn)行虛擬手術(shù)模擬前肩峰成形術(shù)。從肩袖撕裂模型的肩峰前部向后畫出2.5cm區(qū)域的范圍，將該區(qū)域內(nèi)的肩峰下方骨皮質(zhì)磨除；然后將肩峰前部8mm的骨質(zhì)切除掉。通過該手術(shù)后CT肩峰指數(shù)為0.60，CT肩峰側(cè)傾角為82.71°，CT決定性肩角為28.56°，由此可以看出該手術(shù)方式并不能改變肩峰的外側(cè)緣形態(tài)。同時(shí)，外展該模型的肱骨使之達(dá)到肩峰撞擊的位置并進(jìn)行有限元分析。結(jié)果顯示，通過計(jì)算后發(fā)現(xiàn)其外展撞擊后在肌腱與肩峰之間產(chǎn)生的最大應(yīng)力為81.59MPa（平均6.658MPa），相對于肩袖撕裂模型在肌腱處產(chǎn)生的應(yīng)力有所減小，但和正常人的模型相比較，依然有較大的應(yīng)力集中。 第五部分：肩峰外側(cè)緣虛擬切除手術(shù)及有限元分析。從前一部分可以發(fā)現(xiàn)，前肩峰成形術(shù)能夠改善肩袖撕裂模型的在肩峰與肌腱之間產(chǎn)生的應(yīng)力集中，但是治療效果仍有欠缺。因此，我們根據(jù)肩峰的生理解剖結(jié)構(gòu)提出一種肩峰外側(cè)緣切除術(shù)的設(shè)想。在第三部分肩袖撕裂模型的基礎(chǔ)上，在Magics軟件中使用多段線切割功能能將肩峰骨皮質(zhì)的最外側(cè)緣由前向后均勻的切除一部分，切除的骨量沒有固定數(shù)值，目標(biāo)是切除骨皮質(zhì)后使該模型的肩峰指數(shù)、肩峰側(cè)傾角、決定性肩斜角與健康人模型基本保持一致。經(jīng)過測量切除后的模型其CT肩峰指數(shù)為0.45，CT肩峰側(cè)傾角為86.25°，CT決定性肩角為22.48°，各參數(shù)與健康人模型基本一致。有限元分析結(jié)果顯示外展撞擊后肌腱與肩峰之間產(chǎn)生的最大應(yīng)力減小到75.01MPa（平均6.025MPa），可見該方法通過修改肩峰形態(tài)，可以最大程度效緩解肩峰外側(cè)緣產(chǎn)生的撞擊。我們發(fā)現(xiàn)盂肱關(guān)節(jié)軟骨的應(yīng)力減小為43.81MPa（平均12.74MPa），這是一個(gè)有趣的現(xiàn)象，肩峰指數(shù)減小后在撞擊時(shí)盂肱關(guān)節(jié)內(nèi)的應(yīng)力卻減小，這一點(diǎn)和Nyffyler的假設(shè)相反，也就是說盂肱關(guān)節(jié)內(nèi)的壓力并沒有因?yàn)榧绶逯笖?shù)的縮小而增加。 通過上述研究我們認(rèn)為，肩峰向側(cè)方的延展度及向下方的傾斜度過大與肩袖撕裂密切相關(guān)，肩峰向側(cè)方的延展度及向下方的傾斜度過小則有可能是導(dǎo)致肩關(guān)節(jié)容易罹患急性損傷的原因，而這些形態(tài)變異與盂肱關(guān)節(jié)炎的發(fā)生發(fā)展沒有必然聯(lián)系。肩峰指數(shù)、肩峰側(cè)傾角、決定性肩角可以作為臨床診斷上述疾病的輔助指標(biāo)。該研究通過有限元分析發(fā)現(xiàn)，肩袖撕裂患者在肩胛骨平面外展肩關(guān)節(jié)時(shí)，肌腱會(huì)產(chǎn)生較明顯的應(yīng)力集中，前肩峰成形術(shù)可以緩解該處的應(yīng)力集中，但效果有限，如果可以將肩峰外側(cè)緣切除至正常人范圍，則可以更大程度上緩解外展肩關(guān)節(jié)時(shí)肌腱與肩峰的應(yīng)力集中。但這只是通過生物力學(xué)研究后的一種結(jié)論，距離投入臨床實(shí)踐還有很多問題需要解決。
[Abstract]:The variation of the acromial morphology has been considered to be one of the pathogenic factors that cause the rotator cuff injury and the occurrence of glenohumeral arthritis. Many scholars have done a lot of research on the variation of the apoacial morphology and the understanding of the relationship between them. The imaging methods used to describe the morphological variation of the acromion have emerged, and their clinical significance is also constantly being used. Get to know.
At present, scholars at home and abroad have studied the relationship between the acromion index, the acromion angle, the decisive shoulder angle and the shoulder joint disease. Many scholars believe that these indexes can be used as auxiliary clinical parameters for the clinicians to diagnose the disease. However, if these variations occur simultaneously on the same patient, the acromion of the patient has two or more characteristics, such as the large acromion index and the small angle of the acromion, which is synergistic or antagonistic to the development of the disease, which is a synergistic effect. The purpose of this study is to explore the acromion index, the acromion angle, the link between the decisive shoulder angle and the shoulder disease, and the internal rules of the study of these parameters, and to verify the related problems by computer numerical simulation to provide some living things for the treatment of such diseases. The study is divided into two parts: clinical research and computer numerical simulation analysis.
The first part: a clinical study of the acromion index combined with the acromion angle. The purpose of this study was to analyze the links between the acromion index, the acromion angle, the rotator cuff tear and the acute shoulder joint trauma. We measured the shoulder peak index and the acromion angle of the same patient with the true shoulder and front X images. The acromion index and the acromion angle were measured in three groups of cases: 61 patients were included in the shoulder joint acute trauma group, 165 patients were included in the rotator cuff tear group, and 63 patients were included in the healthy control group. The results showed that the average shoulder peak index of the rotator cuff tear group was 0.72 + 0.06, the average acromion angle of the shoulder was 76.8? 7.02, and the acute shoulder was in the shoulder. The average acromion index of the joint injury group was 0.59 + 0.05, the average acromion angle of the shoulder was 84.4? 7.99, and the acromion index of the healthy control group was 0.65 + 0.06, and the acromion index and the acromion angle of the average acromion angle of 80.2? 7.32. were statistically significant (P0.01). It is interesting that the results of the study were first found in each shoulder peak index and shoulder. There is an inverse relationship between the peak side inclination, that is, the greater the extension of the shoulder to the side, the greater the inclination of the shoulder peak downward; on the contrary, the smaller the extension of the shoulder to the side, the smaller the inclination of the shoulder to the lower. This rule shows that the acromion index and the shoulder peak angle are associated with the rotator cuff tear. The small acromion index may be an important factor causing glenohumeral arthritis, but in this part of the study, we did not find a link between the small acromion index and the glenohumeral joint. But we found that in patients with acute shoulder trauma, the average acromion index was significantly lower than that of the control group, so we found that the average acromion index was significantly lower than that in the control group, Nyffeler. We deduce that, as the acromion index is small, the acromion angle is larger, which leads to the reduction of shoulder peak tolerance to the humeral head below it, although the joint flexibility is good, but the stability is poor. On the contrary, the acromion index is large and the acromion angle is small, which will increase the tolerance of the shoulder peak to the humeral head below it, so the joint stability increases but the flexibility is flexible. Lower.
The second part: the clinical study of the acromion index combined with the acromion angle and the decisive shoulder angle. We measured the acromion index, the acromion angle and the decisive shoulder angle by the true anterior and posterior X image of the standard shoulder joint. The study included two groups of cases: 105 patients with rotator cuff tear, and 62 of the healthy control group. The results showed that the mean decisive shoulder angle of the patients with rotator cuff tears was 36.2 + 4.61, the average acromion index was 0.71 + 0.05, the average decisive shoulder angle of the average acromion angle of the acromion is 31.7 / 5.03, the average acromion index was 0.64 + 0.06, the average shoulder angle of the average shoulder peak was 82? 7.53. in each group. The number has statistical significance (P0.01). Through correlation analysis, it is found that the acromion of the two groups has the following rules: the acromion index is inversely proportional to the acromion angle; the acromion index is proportional to the decisive shoulder angle. We call this Law "the acromion law". The degree of increase, will inevitably lead to the increase of downward tilt, resulting in two causes of rotator cuff tear plays a synergistic effect, but the human form will develop into why the acromion so, still can make nothing of it.
The third part: the establishment of the three-dimensional finite element model of the shoulder joint and the finite element analysis of the different forms of the acromion. First, we set up two groups of shoulder joint models of the rotator cuff tears and normal healthy people. Using the CT data of the patients and volunteers, the scapula and the three-dimensional geometric model of the humerus were established by the Mimics software. The model of the CT was established. In order to accurately measure the acromion index, the acromion angle and the decisive shoulder angle, the position of the three dimensional model is adjusted. Then the above parameters are measured on each model, then a shoulder joint model of a rotator cuff tear patient and a healthy person is selected. The three-dimensional geometric model of the upper muscle tendon and the glenohumeral joint cartilage, using the Geomagic Studio optimization model, introduced the Abaqus software to give the material properties of each part and then simulated the abduction impact on the scapula plane, and then analyzed the shoulder joints of different shoulder peaks in the scapular plane abduction, when the shoulder peak and the soft group below the scapula. VonMises stress and strain between the tendon and the cartilage of the glenoid humerus after contact were woven. The results showed that the stress between the tendon and the acromion after the abduction of the rotator cuff model was 172.6MPa (average 12.53MPa), which was significantly greater than that of the healthy human model (mean 5.108MPa), indicating that the rotator cuff tear model would produce more than the tendon in the tendon. Obvious stress concentration. The stress between the humeral head and the scapular cartilage after the abduction of the rotator cuff model was 69.91MPa (mean 16.06MPa) greater than that of the healthy human model (mean 12.61MPa). The results showed that the stress between the rotator cuff tear model in the glenohumeral joint was higher than that of the normal human model when the abduction impact was impacted.
The fourth part: virtual surgery and finite element analysis of anterior acromion. One of the main surgical procedures for the treatment of underacromous impaction is to use arthroscopy for anterior undershoulder plasty, which can relieve the anterior impact of the acromion by modifying the shape of the cortex in the anterolateral shoulder of the shoulder. The impact of the abduction of the shoulder joint at the scapular plane abduction is still lacking in biomechanical studies. The rotator cuff tear model in the third chapter is used in the Magics software to simulate the anterior scapula by virtual surgery (Polyline Cut). The 2.5cm region is drawn from the front of the shoulder of the rotator cuff tear model. To remove the bone cortex below the acromion in the area, remove the bone in the anterior part of the acromion, and remove the 8mm bone in the anterior part of the acromion. After the operation, the CT shoulder peak index is 0.60, the CT acromion angle is 82.71 degrees, and the CT decisive shoulder angle is 28.56 degrees. Thus, it can be seen that the operation method can not change the lateral border of the shoulder peak. The results show that the maximum stress between the tendon and the shoulder peak is 81.59MPa (average 6.658MPa) after the abduction impact, and the stress produced at the tendon of the rotator cuff tear is smaller than that of the rotator cuff tear model, but it is still larger than the normal model. Stress concentration.
The fifth part: virtual excision of the lateral edge of the acromion and finite element analysis. The former part can be found that the anterior acromion can improve the stress concentration between the shoulder and the tendons of the rotator cuff tear model, but the therapeutic effect is still deficient. Therefore, we propose a lateral edge of the acromion according to the physiological anatomy of the acromion. On the basis of the third part of the rotator cuff tear model, the use of multi segment cleavage in the third part of the rotator cuff model can remove the most lateral origin of the acromion cortex from the anterior and the backward, with no fixed value, the target is to excise the bone cortex and make the shoulder peak index, the acromion angle, and the decisive shoulder. The slope angle was basically consistent with that of the healthy person model. The CT acromion index of the model after the measurement was 0.45, the CT acromion angle was 86.25 degrees, the CT decisive shoulder angle was 22.48 degrees, and the parameters were basically the same as the healthy person model. The finite element analysis showed that the maximum stress between the tendon and the shoulder peak after the abduction impact was reduced to 75.01MPa (flat). 6.025MPa), we can see that by modifying the acromion shape, the impact of the lateral edge of the acromion can be relieved to the maximum effect. We found that the stress of the cartilage of the glenoid humerus is reduced to 43.81MPa (average 12.74MPa). This is an interesting phenomenon, and the stress in the glenohumeral joint decreases when the acromion index decreases, and this point and the Nyffyler are reduced. The hypothesis is that the pressure in the glenohumeral joint is not increased due to the reduction of the acromion index.
Through these studies, we believe that the extension of the shoulder to the side and the downward tilt are closely related to the rotator cuff tear. The ductility of the acromion to the side and the lower inclination may be the cause of the acute injury of the shoulder joint, and these forms of variation and the occurrence and development of the glenohumeral arthritis are not. The acromion index, the acromion angle and the decisive shoulder angle can be used as an auxiliary indicator for the clinical diagnosis of the above diseases. The study shows that the tendons can produce a more obvious stress concentration when the shoulder sleeve tearing patients abduct shoulder joints in the scapular plane through the finite element analysis. If it is limited, if the lateral edge of the acromion can be removed to the normal range, the stress concentration of the tendons and acromion of the abductor shoulder joint can be greatly relieved. But this is only a conclusion after the biomechanical study, and there are many problems to be solved in clinical practice.
【學(xué)位授予單位】：吉林大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2015
【分類號(hào)】：R684

【共引文獻(xiàn)】

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相關(guān)博士學(xué)位論文 前2條

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相關(guān)碩士學(xué)位論文 前10條

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本文編號(hào)：2046168