高脱位DDH全髋置换屈髋外展屈膝体位对坐骨神经安全性的影响

发布时间：2018-03-17 02:27

本文选题：高脱位　切入点：髋关节置换　出处：《第三军医大学》2015年博士论文　论文类型：学位论文

【摘要】：研究背景成人高脱位髋关节发育不良(Development Dysplasia of the Hip, DDH)可造成双下肢不等长,髋关节外展受限,骨盆倾斜,脊柱侧弯,力线不正而加速膝关节退变,严重影响患者生活质量。成人高脱位DDH病理复杂,这样导致在治疗上非常棘手,行全髋关节置换(Total Hip Arthroplasty,THA)是一种较好的办法。但,由于长期高脱位,尤其是单侧股骨头旋转中心相对真臼旋转中心上移大于4cm者,THA治疗更加具有挑战性。股骨头旋转中心严重上移,与真臼的旋转中心相距较远,给全髋关节置换治疗高脱位成人DDH带来术中复位困难,损伤神经血管的可能性很大,尤其是坐骨神经(Sciatic nerve,SN)损伤有极大的风险。有在假臼重建髋臼杯；短缩股骨截骨；一期松解髋关节延长肢体,下移股骨头旋转中心,二期行THA,等方法。这些方法能够缓解复位的难度和减少神经损伤的并发症,但是也增加了其他的并发症。真臼重建非股骨短缩截骨THA在治疗高脱位DDH方面,屈髋可以降低股神经(Femal Nerve,FN)的张力和增加坐骨神经张力,髋外展和屈膝能降低坐骨神经张力,但是,髋外展屈髋屈膝的组合体位对坐骨神经的影响还有待研究。因此,本研究为了探索客观的临床实施依据,特进行此坐骨神经生物力学基础实验研究并在临床中进行进一步研究。研究方法1.高脱位DDH真臼重建非短缩截骨全髋关节置换复位技术及神经安全管理。在2004年12月与2012年9月间18例高脱位(Crowe's IV型)DDH病例,股骨头旋转中心上移大于4cm,股骨近端无弯曲畸形,无肢体神经肌肉疾病。所有患者均获得本人或其委托人的同意,愿意承担各种手术风险,构成良好依从性者。予自行设计的会阴横档牢固固定患者,复位前一分钟罗库溴铵3倍(E95)注射松弛肌肉,复位并髋外展30°屈髋60°屈膝90°严格坐骨神经管理。术前记录股骨头旋转中心与真臼旋转中心的距离和髋关节Harris评分,进行术前术后比较,应用SPSS15.0软件进行F检验处理数据。2.三维运动模型模拟下肢体位变化对坐骨神经长度的影响。应用螺旋CT采集人体数据,Mimics16.0软件构建三维运动模型,Geomagic2013软件后处理,UG9.0软件进行坐骨神经描点计算髋膝关节不同体位坐骨神经长度。分别在下肢伸直位、髋外展0°屈髋60°屈膝90°和髋外展30°屈髋60°和屈膝90°时,计算三种体位组合的坐骨神经长度。3.犬下肢体位变化对坐骨神经张力和位移影响的生物力学分析。应用4只贵州下司犬,去除盆腔内脏,在骶丛神经与坐骨神经移行处切断,用无张力细线连接坐骨神经断端于张力传感器,测量坐骨神经断端在下肢伸直位、髋外展30°屈髋120°屈膝135°位、髋外展30°屈髋60°屈膝120°位、髋外展30°屈髋60°屈膝90°位、髋外展30°屈髋60°屈膝60°位、髋外展30°屈髋60°屈膝30°位等体位时的张力和等张力下的位移。应用SPSS15.0软件进行F检验比较各体位组合的坐骨神经近端的张力和位移变化。研究结果1.高脱位DDH真臼重建非短缩截骨全髋置换,应用髋外展30°屈髋60°和屈膝90°,可避免坐骨神经损伤。所有患者获得随访,时间在12月至108月,平均76月。股骨头旋转中心均到达真臼旋转中心,患肢延长从40mm到68mm(48.65±7.28mm)。双下肢肢体长度差异0-16mm(5±4mm)。最后一次Harris评分87.3±10.6,术前术后比较有显著性差异。有4髋因术中假体植入过程中出现轻微劈裂骨折,立即拔出股骨柄假体,在股骨近端,小粗隆处捆扎钢缆后,重新植入假体,则获得牢固的初始稳定。3髋有坐骨神经不完全损伤,4周后完全恢复。2髋出现小腿以远感觉运动功能受损,4周后感觉恢复,膝踝关节出现疼痛,MRI未见异常,2月后对症处理后好转。无股神经损伤及其他严重并发症。2.在三维运动模型模拟中,髋外展30°屈髋60°和屈膝90°时,坐骨神经可延长距离最大。3D运动模型能成功计算髋膝关节不同体位坐骨神经长度。在下肢伸直位、髋外展0°屈髋60°屈膝90°和髋外展30°屈髋60°和屈膝90°时,三种体位组合的坐骨神经长度中,坐骨神经长度依次降低,最大差异约27mm。3.在犬的实验中,髋外展30°屈髋60°和屈膝90°时,坐骨神经张力较小,可位移较大。在髋关节外展30°前提下,在屈髋60°屈膝120°时,坐骨神经近端张力和位移较小；在屈髋60°屈膝90°时,张力和位移稍微高于屈髋60°屈膝120°时,但是此两组间比较无统计学意义,两组间差异无显著性,P0.05。其他所有组间比较均有统计学意义,P0.05。在髋关节外展30°屈髋60°屈膝90°位,是张力较小的和位移较大的。研究结论1.能成功实现真臼重建髋臼杯非股骨短缩截骨THA治疗高脱位DDH。应用牢固固定病人手术体位、罗库溴铵松弛肌肉并合理松解软组织获得复位,复位时髋内收20°屈髋60°屈膝90°时,复位成功后髋外展30°屈髋60°屈膝90°能避免坐骨神经损伤。2.应用螺旋CT采集人体数据,Mimicsl6.0软件建三维运动模型,Geomagic2013软件后处理,UG9.0软件进行坐骨神经描点模型能成功计算髋膝关节不同体位坐骨神经长度。髋外展30°屈髋60°和屈膝90°时,能增加在肢体延长中同时增加坐骨神经延长度而减少神经损伤可能。3.在髋膝关节活动过程中,坐骨神经的张力主要与肢体软组织张力大小和髋关节的活动度成正比,与膝关节活动范围在0°-120°时成反比。坐骨神经近端的位移主要与肢体软组织张力大小和髋关节的活动度成反比,与膝关节活动范围在0°-120°时成正比。在外展30°屈髋60°屈膝90°时,有利于下肢神经张力的降低,能较好的避免坐骨神经的损伤。
[Abstract]:The research background of adult higher dislocation of hip dysplasia (Development Dysplasia of the Hip, DDH) can be made into double limb length, hip abduction, pelvic tilt, scoliosis, alignment and accelerate the degeneration of the knee, seriously affects the life quality of the patients. The adult higher dislocation DDH pathology is complex, resulting in the treatment of is very difficult, for total hip replacement (Total Hip, Arthroplasty, THA) is a kind of good way. However, due to the long-term high dislocation, especially on one side of the femoral head center true acetabular rotation center up relative greater than 4cm, THA treatment is more challenging. The femoral head center and the rotation center really serious shift the mortar is far apart, for total hip replacement in the treatment of adult DDH with high dislocation reset difficulties, possibility of great damage to nerves and blood vessels, especially the sciatic nerve injury (Sciatic nerve, SN) has a great wind There are risks. In false acetabulum reconstruction of acetabular cup; femoral shortening osteotomy; a loose hip extension of the body, down the center of the femoral head, two stage THA, and other methods. These methods can alleviate the difficulty of the reset and reduce the complication rate, but also increases the complication of others. The true acetabulum reconstruction of femoral shortening osteotomy in the treatment of THA high dislocation DDH, hip flexion can reduce the femoral nerve (Femal Nerve, FN) and increase the tension of the sciatic nerve tension, hip abduction and flexion can reduce the sciatic nerve tension, but the combination of postural hip abduction hip flexion bending effect on sciatic nerve remains to be studied. Therefore, this study in order to explore the objective clinical basis for implementation of the sciatic nerve, the special biomechanical basis of experimental research and further research in clinical research. Methods 1. high dislocation DDH true acetabular reconstruction non shortening osteotomy in Total Hip Arthroplasty replacement Technology and nerve safety management. In December 2004 and September 2012 18 cases of high dislocation (Crowe's IV type) DDH cases, the center of the femoral head up more than 4cm, the proximal femur without bending deformity, no limb neuromuscular disease. All patients got himself or his client's consent, willing to bear all the risk of surgery, a good compliance. Perineum were treated with self-designed fixed rungs, one minute before the reduction of rocuronium 3 times (E95) injection of muscle relaxation, reduction and abduction of hip hip flexion 30 degrees 60 degrees at 90 degrees in strict management. The sciatic nerve was recorded preoperatively femoral head center and the rotation center distance and the true acetabulum the Harris hip score, postoperative comparison, application of SPSS15.0 software for F test data.2. model to simulate the three-dimensional motion of lower limb postural change effect on sciatic nerve length. Application of spiral CT acquisition of human data, Mimics16 The three-dimensional motion model of.0 software, Geomagic2013 software and UG9.0 software for postprocessing, sciatic nerve tracing point calculation of hip and knee position sciatic nerve length. In a straight leg, hip hip flexion 0 degrees 60 degrees at 90 degrees and 30 degrees of hip flexion hip abduction and flexion 60 degrees 90 degrees, biomechanical analysis calculation the length of the sciatic nerve.3. dog leg position change of three kinds of combination of position effect on sciatic nerve tension and displacement. The application of the 4 Guizhou Geji dogs, removal of pelvic visceral, transitional cut in the sacral plexus and sciatic nerve, with no tension in the broken ends of the sciatic nerve connection thread tension sensor, measurement of sciatic nerve stump in straight leg, hip hip flexion 30 degrees 120 degrees at 135 degrees, 30 degrees of hip flexion hip abduction 60 degrees at 120 degrees, 30 degrees of abduction of hip flexion of the hip flexion 60 degrees 90 degrees, 30 degrees of hip flexion hip abduction 60 degrees at 60 degrees, 30 degrees of hip flexion hip abduction 60 degrees 30. The displacement of tension and tension degrees etc. position under tension and displacement. SPSS15.0 software was used for F test comparing the combination of the sciatic nerve proximal position. The results of 1. high dislocation DDH true acetabular reconstruction non shortening osteotomy in total hip arthroplasty, application of hip abduction 30 degrees 60 degrees of knee flexion and hip flexion 90 degrees, can avoid the injury of sciatic nerve. All patients were followed up, the time from December to 108 months, average 76 months. The femoral head center arrives at the true acetabular rotation center, limb extended from 40mm to 68mm (48.65 + 7.28mm). The double lower limb length difference of 0-16mm (5 + 4mm) last time. The Harris score was 87.3 + 10.6, before and after surgery had significant difference. 4 for hip prosthesis implantation in the course of minor fracture, immediately unplug the femoral prosthesis, in the proximal femur lesser trochanter tied cable after reimplantation was strong initial stability.3 hip sit Bone nerve injury, 4 weeks after complete recovery of.2 hip leg sensorimotor function beyond impaired sensory recovery after 4 weeks, knee and ankle joint pain, MRI is no exception, in February after the symptomatic treatment. No femoral nerve injury and other serious complications of.2. in 3D motion simulation, hip abduction 30 60 degrees of hip flexion and knee flexion angle of 90 degrees, the sciatic nerve can extend the maximum distance.3D motion model can successfully calculate the hip and knee position sciatic nerve length. In a straight leg, hip flexion hip abduction 0 degrees 60 degrees at 90 degrees and 30 degrees of hip flexion hip abduction and flexion 60 degrees 90 degrees, three different combination of sciatic nerve length, sciatic nerve length decreased, the biggest difference about 27mm.3. in dogs, hip abduction 30 degrees of hip flexion at 90 degrees and 60 degrees, the sciatic nerve tension can be smaller, larger displacement at the hip. 30 degrees of abduction in the premise of hip flexion 60 degrees at 120 Degrees, the sciatic nerve proximal tension and the displacement is small; in hip flexion 60 degrees at 90 degrees, the tension and displacement is slightly higher than the 60 degrees of hip flexion at 120 degrees, but no statistical significance between the two groups, no significant differences between two groups of P0.05., all the other groups had statistical significance. P0.05. in hip abduction 30 degrees of hip flexion 60 degrees flexion 90 degrees, tension is smaller and larger displacement. The conclusion of the study 1. can achieve the true acetabular reconstruction of acetabular cup femoral shortening osteotomy THA treatment position high dislocation DDH. application fixation surgery, rocuronium muscle relaxation and reasonable the solution of soft tissue gain reduction, reduction of hip adduction 20 degrees of hip flexion 60 degrees at 90 degrees, 30 degrees of abduction of hip after successful reduction of hip flexion 60 degrees at 90 degrees to avoid injury of the sciatic nerve.2. application of spiral CT acquisition of human data, Mimicsl6.0 software to build three-dimensional model, Geomagic2013 software. UG9.0 software, sciatic nerve tracing point model can calculate the hip and knee position sciatic nerve length. Hip abduction 30 degrees of hip flexion at 90 degrees and 60 degrees, can increase during limb lengthening and increase sciatic nerve elongation and reduce nerve injury.3. in hip and knee joint activity during sciatic the main nerve tension and limb soft tissue tension and hip joint activity is proportional to the degree, and the range of motion of knee joint in 0 degrees -120 degrees is inversely proportional to the displacement of the proximal end of the sciatic nerve and limb soft tissue tension and hip joint activities inversely, and the range of motion of knee joint in 0 ~ -120 the degree is proportional to. In 30 degrees of abduction of hip flexion 60 degrees at 90 degrees, can reduce lower extremity nerve tension, can better avoid the sciatic nerve injury.

【学位授予单位】：第三军医大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R687.4

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