β-磷酸三钙生物陶瓷棒系统治疗早期股骨头坏死的临床观察与生物力学研究

发布时间：2018-01-22 01:19

本文关键词： 股骨头坏死保髋治疗临床疗效生物陶瓷 β-磷酸三钙有限元分析股骨头坏死应力位移载荷步态 β-磷酸三钙生物陶瓷　出处：《广西医科大学》2017年博士论文　论文类型：学位论文

【摘要】：第一部分β-磷酸三钙生物陶瓷棒系统治疗早期股骨头坏死的临床研究目的:观察β-磷酸三钙生物陶瓷棒系统植入术治疗早期股骨头坏死的短期临床疗效,探讨术前因素(年龄、BMI指数、病程时间、病因、坏死范围、骨髓水肿分级、术前髋关节Harris评分和术前髋关节疼痛VAS评分)对β-磷酸三钙生物陶瓷棒植入术疗效的影响。方法:对2015年4月到2015年8月收治的接受β-磷酸三钙陶瓷棒系统植入手术治疗的股骨头坏死患者34例(35髋)进行术后短期的观察及随访。对术前、术后第6个月,术后第12个月,术后第18个月髋关节Harris评分、髋关节Harris评分优良率及髋关节疼痛VAS评分进行统计学分析。从术后第6个月,术后第12个月,术后第18个月进行影像学的评价。分析术前年龄、BMI指数、病程时间、病因、坏死范围、骨髓水肿分级、术前髋关节Harris评分及术前髋关节疼痛VAS评分与术后髋关节Harris评分及术后髋关节疼痛VAS评分的相关性。结果:所有患者均随访至术后18个月。(1)髋关节Harris评分结果术后各时间点的髋关节Harris评分均分别较术前髋关节Harris评分有明显提高,差异具有统计学意义(P0.05);术后髋关节Harris评分优良率明显提高。(2)髋关节疼痛VSA评分的结果术后各时间点的髋关节疼痛VAS评分均分别较术前髋关节疼痛VAS评分有明显降低,差异具有统计学意义(P0.05)(3)术前各因素与术前髋关节Harris评分的关系年龄、BMI指数、病程时间、病因、坏死范围、骨髓水肿分级和术前髋关节疼痛VAS评分均与术前髋关节Harris评分无相关性(P0.05)。(4)术前各因素与术前髋关节疼痛VAS评分的关系骨髓水肿分级与术前髋关节疼痛VAS评分成正相关性(P0.05),其余因素无相关性(P0.05)。(5)术前各因素与术后髋关节Harris评分的关系年龄、BMI指数、病变范围和术前髋关节Harris评分与术后髋关节Harris评分有相关性(P0.05),其余因素无相关性(P0.05)。(6)术前各因素与术后髋关节疼痛VAS评分的关系BMI指数和病变范围与术后髋关节疼痛VAS评分有相关性(P0.05),其余因素无相关性(P0.05)。(7)影像学结果35髋按照ARCO分期进行影像学评估,至术后6个月时,稳定24髋,稳定率68.57%;至术后12个月时,稳定27髋,稳定率77.14%;至术后18个月时,稳定31髋,稳定率88.57%。3髋发生股骨头塌陷,术后18个月时的保髋率为91.43%。结论:采用β-磷酸三钙生物陶瓷棒系统植入术治疗早期股骨头坏死,可有效改善髋关节功能,缓解症状,阻止影像学进展,获得比较高的保髋率,近期疗效满意。在进行临床疗效评估及手术适应症选择时,需要考虑年龄、BMI指数、病变范围和术前髋关节Harris评分因素的影响。第二部分基于三维有限元分析的β-磷酸三钙生物陶瓷棒系统治疗早期股骨头坏死的生物力学研究目的:应用三维有限元方法,建立坏死股骨头病灶及植入β-磷酸三钙生物陶瓷棒系统后的股骨头三维有限元模型,观察β-磷酸三钙生物陶瓷棒系统植入术对早期股骨头坏死的生物力学影响,为β-磷酸三钙生物陶瓷棒系统治疗股骨头坏死提供力学方面的理论依据。方法:利用CT对一名健康成年男性髋关节进行薄层扫描,建立正常股骨近端有限元模型,在此基础上建立坏死区域位于前外上侧15%、后外上侧15%、前外上侧30%、后外上侧30%与负重区塌陷2mm、负重区塌陷4mm的早期坏死股骨头及模拟植入β-磷酸三钙生物陶瓷棒系统后的股骨头有限元模型,分别加载普通行走、慢速跑步、快速跑步三种力学载荷,观察β-磷酸三钙生物陶瓷棒系统治疗前后股骨头应力及位移变化情况,并判断不同步态下股骨头塌陷的风险。结果:(1)在普通步行、慢速跑步、快速跑步三种载荷下,相比治疗前,治疗后股骨头应力集中现象有所改善,股骨头应力值与整体位移值,股骨头负重区应力值与塌陷值,坏死区应力值与位移值较治疗前减小,差异具有统计学意义(P0.05)。随着载荷的增加,坏死股骨头的应力与整体位移值,股骨头负重区应力值与塌陷值,坏死区应力值与位移值随之增大。坏死范围15%与30%位于前外上侧与后外上侧,股骨头应力值与塌陷值,坏死区应力值与位移值均无明显差异(P0.05)。(2)根据塌陷准则,在普通步行、慢速跑步、快速跑步下,术前与术后坏死范围30%比坏死范围15%的股骨头塌陷风险大,塌陷4mm比塌陷2mm的股骨头再次塌陷风险大,且随着载荷的加大,塌陷风险增加。术后塌陷风险比术前塌陷风险有所降低,但随着载荷的加大,塌陷风险增加。坏死范围15%与30%位于前外上侧与后外上侧,塌陷风险无太大差别。结论:(1)有限元分析模型能够有效模拟β-磷酸三钙生物陶瓷棒系统植入股骨头坏死区域的生物力学变化。(2)β-磷酸三钙生物陶瓷棒系统植入可有效改善坏死股骨头内部的力学性能,增加坏死股骨头负重区骨的支撑能力,降低坏死区骨的压应力,减少坏死股骨头塌陷的风险。(3)β-磷酸三钙生物陶瓷棒系统的力学支撑能力有限,随着载荷的增加,坏死股骨头塌陷的风险逐渐增大。对于坏死范围较小及塌陷程度轻的效果要好于坏死范围较大及塌陷程度重的股骨头坏死。(4)从生物力学角度进行疗效评价,为β-磷酸三钙陶瓷棒系统治疗股骨头坏死提供生物力学方面的理论依据。
[Abstract]:The first part is clinical study of tricalcium phosphate ceramic rod system in the treatment of early femoral head necrosis: short term clinical observation of tricalcium phosphate ceramic rod system implantation in the treatment of early avascular necrosis of the femoral head, to investigate the preoperative factors (age, BMI index, disease duration, etiology, necrosis, bone marrow edema grading, preoperative Harris hip score and preoperative hip pain VAS score) effect on tricalcium phosphate ceramic rod implantation. Methods: from April 2015 to August 2015 were treated with beta tricalcium phosphate ceramic rod system implanted into the surgical treatment of femoral head necrosis in 34 patients (35 hips) observation the short-term and follow-up after surgery. Preoperative, postoperative sixth months, twelfth months after the surgery, postoperative Harris hip score at eighteenth months, Harris hip score and excellent rate of hip joint pain VAS score was statistically analyzed. The postoperative Sixth months, twelfth months after the operation was evaluated eighteenth months after surgery. The imaging analysis of preoperative BMI index, age, disease duration, etiology, necrosis, bone marrow edema grading, preoperative Harris hip score and preoperative hip pain VAS score and postoperative Harris hip rating. And after hip joint pain VAS score. Results: all patients were followed up to 18 months after the operation. (1) hip Harris score after hip joint Harris each time point scores were compared with the preoperative Harris hip score increased significantly, the differences were statistically significant (P0.05); operation after the Harris hip score excellent rate increased. (2) hip pain VSA scores after hip joint pain VAS at different time points were respectively compared to the preoperative hip pain VAS score was significantly decreased, the difference was statistically significant (P0.05) (3) preoperative factors and preoperative hip The relationship between age, Harris score BMI index, disease duration, etiology, classification and operation scope of necrosis, bone marrow edema before hip pain VAS score and preoperative Harris hip score had no correlation (P0.05). (4) the relationship between preoperative grading of bone marrow edema and operation factors and preoperative VAS score of hip joint pain the hip joint pain VAS score was positively correlated (P0.05), there was no correlation between other factors (P0.05). (5) preoperative factors and postoperative Harris hip score between age, BMI index, lesion area and preoperative Harris hip score and postoperative Harris hip score correlation (P0.05), no correlation between other factors (P0.05). (6) preoperative factors and postoperative hip pain VAS score between BMI index and the extent of the lesion and postoperative hip pain VAS score correlation (P0.05), there was no correlation between other factors (P0.05). (7) the imaging results of 35 hips with ARCO Staging imaging assessment at 6 months after operation, stable in 24 hips, stable rate of 68.57%; and 12 months after operation, stable in 27 hips, stable rate of 77.14%; and 18 months after operation, stable in 31 hips, stable rate of 88.57%.3 hip femoral head collapse, hip preserving 18 months the rate of postoperative 91.43%. conclusion: using tricalcium phosphate ceramic rod system implantation in the treatment of early avascular necrosis of the femoral head, can effectively improve the hip joint function, relieve symptoms, prevent radiographic progression, get hip preserving high rate, the short-term curative effect is satisfactory. In clinical curative effect evaluation and surgical indications when the need to consider the age, BMI index, Harris score of hip joint lesion and preoperative factors. The second part is to study the biomechanical three dimensional finite element analysis of tricalcium phosphate ceramic rod system in the treatment of early avascular necrosis of the femoral head based on Application of 3D finite element method is established A three-dimensional finite element model of avascular necrosis of the femoral head lesions and implantation of tricalcium phosphate ceramic rod system, observe the biomechanical effects of tricalcium phosphate ceramic rod system implantation for early avascular necrosis of the femoral head, the theoretical basis for tricalcium phosphate ceramic rod system in the treatment of femoral head necrosis with mechanics.. method: TLC scanning of a healthy adult male hip by CT, the establishment of normal proximal femur finite element model is established on the basis of necrotic area located on the front side of the outer side outside the 15%, after 15%, before the upper 30%, after the upper 30% and weight-bearing area of collapse 2mm, 4mm early necrosis of femoral simulation of bone and implant tricalcium phosphate ceramic rod system finite element model of the femoral head after the weight-bearing area collapse, were loaded with common walking, slow running fast, running three kinds of mechanical load, observation of tricalcium phosphate The ceramic rod system in the treatment of femoral head before and after the change of stress and displacement, and determine the collapse of femoral head under different gait risk. Results: (1) in normal walking, slow running, fast running under three loads, compared with before treatment, the stress concentration phenomenon has been improved after the treatment of femoral bone, femoral head stress value with the overall displacement and stress value of the weight-bearing area of femoral head necrosis area and subsidence value, stress value and displacement value decreased than that before treatment, the difference was statistically significant (P0.05). With the increase of load, stress and displacement value of femoral head necrosis of the femoral head weight-bearing stress value and subsidence value. The necrosis area of stress value increases with the displacement range of 15% and 30%. Necrosis located in the anterior and outer side after upper femoral head stress value and subsidence value, the necrosis area of stress value and displacement value had no significant difference (P0.05). (2) according to the collapse criterion, in ordinary walking, slow running, Run quickly, preoperative and postoperative necrosis of 30% than 15% necrosis of femoral head collapse risk, 4mm 2mm collapse of the femoral head collapse risk of collapse, and with the increasing of load, increase the risk of postoperative collapse. The collapse risk than preoperative collapse risk decreased, but with the increasing of load. Collapse risk. 15% and 30% in the necrosis range before and after the collapse of upper side, the risk is no big difference. Conclusion: (1) the finite element analysis model can effectively simulate the biomechanical changes of tricalcium phosphate ceramic rod system implanted in the femoral head necrosis region. (2) beta tricalcium phosphate bioceramic rod system implantation can effectively improve the mechanical properties of the internal necrosis of the femoral head necrosis, increase the weight-bearing area of femoral head bone support ability, reduce the necrotic bone stress and reduce the risk of collapse of the femoral head necrosis. (3) beta three phosphate bioceramics The ability of the mechanical support rod system is limited, with the increase of the load, necrosis of femoral head collapse risk increases gradually. The smaller is better necrosis and collapse degree of light in a wide range of necrosis and collapse of femoral head necrosis degree. (4) to evaluate the curative effect from a biomechanical perspective, a theoretical basis for beta tricalcium phosphate the ceramic rod system in the treatment of avascular necrosis of the femoral head to provide biomechanical aspects.

【学位授予单位】：广西医科大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R681.8

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