压力状态下股骨转子间受力的生物力学研究及股骨转子间骨折治疗的荟萃分析

发布时间：2018-03-13 14:24

本文选题：股骨转子间内侧壁　切入点：股骨转子间外侧壁　出处：《山西医科大学》2017年博士论文　论文类型：学位论文

【摘要】：第一部分压力状态下股骨转子间内侧壁及外侧壁受力的生物力学研究目的:本部分研究通过对离体股骨标本转子间进行内侧壁或外侧壁缺损造模,测定并比较内侧壁或外侧壁缺损后以及经过载断裂后行股骨近端防旋髓内钉(PFNA)内固定后股骨转子间的力学负载及应变变化。方法:将纳入研究的12对离体股骨标本随机分为内侧壁组和外侧壁组,并对每组内股骨标本行骨密度(BMD)测定。随机挑选一侧股骨,按分组行股骨转子间内侧壁或外侧壁缺损造模处理。在PFNA植入前后,利用单轴应变片对股骨转子间的应变分布进行测量。使用力学实验机模拟单足站立时角度施加轴向载荷,直至达到破坏载荷。在350 N、700 N、1800 N的载荷水平及破坏载荷下分别记录每个股骨样本的轴向位移以及各测试点的应变值,并计算轴向刚度。将内、外侧壁组中数据汇总并判断其可比性后,比较分析内外侧壁组间的破坏载荷、轴向刚度以及各测试点的应变值。结果:所有内侧壁组及外侧壁组纳入的股骨样本其破坏载荷在不同状态之间均有显著差异(p0.05)。行PFNA内固定后,其提供的轴向破坏载荷高达4.5倍体重左右,可满足日常活动需要。当股骨转子间内侧皮质缺损后,其所受应力应变主要集中于前侧、外侧以及后侧皮质,尤以后侧皮质为著;当行PFNA内固定术后,其所受应力应变主要集中于前侧皮质,并较缺损组股骨能减小其在内侧皮质所受应变,且能撤销其在外侧以及后侧皮质的应力集中。当股骨转子间外侧皮质缺损后,其所受应力应变主要集中于内侧以及后侧皮质,尤以后侧皮质为著;当行PFNA内固定术后,其所受应力应变主要集中于前侧皮质,并较缺损组股骨能减小其在内侧及后侧皮质所受应变值,撤销其应力集中。结论:当股骨转子间内侧壁或外侧壁缺损后,其破坏载荷、轴向刚度均明显减少。而PFNA作为一种治疗股骨转子间骨折的方式,其提供的轴向破坏载荷可满足日常活动需要。股骨转子间内侧壁较外侧壁更为重要,其存在与完整可增加股骨破坏载荷、维持股骨轴向刚度,降低PFNA术后股骨转子间前后侧皮质间的应变差距。而前侧皮质可能是PFNA置入后维持其稳定性的重要原因。第二部分髓内钉固定和髋关节置换治疗股骨转子间骨折的荟萃分析目的:目前,对股骨转子间骨折行髓内钉固定与髋关节置换术治疗的研究越来越多,但两种治疗方法间仍然存在争议。本研究目的在于,通过荟萃分析(Meta分析)研究方法,对这两种治疗股骨转子间骨折方法的有效性及安全性做一综合性分析与判断,从而能使之更好的服务于临床决策。方法:根据既定的纳入标准与排除标准,在1980年1月至2016年9月的时间范围内对Pub Med,Embase和Cochrane Library数据库中搜索相关研究,并限定为英文文献。使用Review Manager 5.3软件进行两种治疗方法间术中信息和术后结果的对比分析。结果:本研究共纳入符合入选标准的11项研究共1239例患者。与髓内钉固定相比,使用髋关节置换术治疗股骨转子间骨折,可以减少内置物相关并发症(OR:2.05,p=0.02)以及降低再手术率(OR:7.06,p0.001)。同时髋关节置换与髓内钉固定具有相似的住院时间(WMD:-0.41,p=0.63)。然而,髓内钉固定与髋关节置换相比,可明显减少术中出血量(WMD:-375.01,p=0.001)和输血例数(OR:0.07,p0.001),缩短手术时间(WMD:-18.92,p=0.010),提高术后髋关节Harris评分(WMD:4.19,p0.001),降低术后1年内死亡率(OR:0.67,p=0.02)。结论:目前,股骨转子间骨折的主流治疗方法仍是髓内钉固定。在没有明确指征的情况下,应慎重选择髋关节置换术,并应知晓髋关节置换术在老年患者中的复杂性与风险。
[Abstract]:The first part studied inbiomechanical objective under pressure of femoral intertrochanteric medial and lateral wall stress: this part of the study based on the inner wall or outer wall defect model of isolated femoral intertrochanteric specimens, to determine and compare the inner wall or outer wall defect after and after loading fracture underwent proximal femoral antirotation nail (PFNA) internal fixation of intertrochanteric mechanical load and strain changes. Methods: the study of 12 isolated femur specimens were randomly divided into medial wall and lateral wall of group group, and each group of specimens of femoral bone mineral density (BMD) were randomly selected. The side of the femoral, grouped by femoral intertrochanteric medial wall or lateral wall defect model. In the PFNA before and after implantation, to measure the strain distribution of femoral intertrochanteric with uniaxial strain gauges. Simulation of single foot stand when the angle of axial load applied by the mechanical testing machine, until the The failure load. At 350 N, 700 N, strain axial displacement were recorded each femur sample load level and load of 1800 N and the value of each test point, and calculate the axial stiffness of the lateral wall. Within the group data collection and determine the comparability, comparative analysis of the failure load and lateral the wall between the groups, the axial stiffness and strain values of each test point. Results: all the medial wall and lateral wall of the group were included in the failure load of femoral samples in different states have significant differences between (P0.05) PFNA. After fixation, the axial load of up to 4.5 times the weight, can meet the needs of daily activities. When the intertrochanteric medial cortical defect, the stress strain mainly concentrated in the front, lateral and posterior cortex, especially the cortex is; when PFNA fixation, the stress strain mainly concentrated in the anterior cortex, And a group of femoral defect can decrease by the strain in the medial cortex, and can cancel the outside and the stress concentration of the posterior cortex. When intertrochanteric lateral cortical defect, the stress strain mainly concentrated in the medial and posterior cortex, especially the cortex to do; PFNA internal fixation then, the stress and strain are mainly concentrated in the anterior cortex, and femoral defect group can reduce the strain values in the medial and posterior cortex, cancel the stress concentration. Conclusion: when the intertrochanteric medial wall or lateral wall defect, the failure load, the axial stiffness was significantly reduced. PFNA as a way of treating intertrochanteric fractures, which provides axial failure load can meet the needs of daily activities. The intertrochanteric medial wall of the outer wall is more important, its existence and integrity can be increased femoral fracture load, maintain the axial stiffness of the femur, Reduce the PFNA postoperative femoral intertrochanteric anterior and posterior cortex of the anterior cortical strain gap. And may be an important factor to maintain its stability after PFNA implantation. Screw fixation and hip replacement in the treatment of femoral intertrochanteric fractures: a meta analysis to second part intramedullary: at present, more and more research on fixation and treatment of hip replacement intramedullary nailing for femoral fracture between the rotor, but the two kinds of treatment methods are still controversial. The purpose of this study is, through meta analysis (Meta analysis) method of the two methods of treatment of intertrochanteric fractures of the efficacy and safety of doing a comprehensive analysis and judgment, so as to make it better the service in clinical decision making. Methods: according to the inclusion criteria and the exclusion criteria, from January 1980 to September 2016 the time range of Pub Med, Embase Cochrane and related research search in the Library database, and Limited to English literature. The comparative analysis of the results of the two methods in the treatment of information and postoperative patients after using Review Manager 5.3 software. Results: the study included 11 study inclusion criteria with a total of 1239 cases of patients with intramedullary nail fixation compared with hip arthroplasty for the treatment of femoral intertrochanteric fracture, can to reduce the complications related to (OR:2.05, p=0.02) and lower reoperation rate (OR:7.06, p0.001). At the same time, hip replacement and intramedullary nailing with similar hospitalization time (WMD:-0.41, p=0.63). However, intramedullary nail fixation and hip replacement, can significantly reduce the amount of bleeding (WMD:-375.01 p=0.001) and blood transfusion cases (OR:0.07, p0.001), shorten the operation time (WMD:-18.92, p=0.010), improve the postoperative Harris hip score (WMD:4.19, p0.001), reduce the mortality rate within 1 years after surgery (OR: 0.67, p=0.02). Conclusion: the intertrochanteric bone The main way of treatment is the intramedullary nailing. If there is no definite indication, we should carefully choose hip arthroplasty, and we should know the complexity and risk of hip replacement in elderly patients.

【学位授予单位】：山西医科大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R687

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