老年髋臼骨折相关临床与生物力学研究

发布时间：2018-05-16 01:00

本文选题：髋臼骨折 + 老年人　；参考：《苏州大学》2015年博士论文

【摘要】：第一部分老年髋臼骨折的流行病学及临床影像学特征目的:分析老年髋臼骨折的流行病学特征,并比较老年与年轻髋臼骨折的临床与影像学特征。方法:回顾分析1990年1月至2013年12月,苏州大学附属第一医院收治髋臼骨折患者的临床资料。根据一定的纳入与排除标准,共637例(637髋)髋臼骨折纳入分析。根据患者年龄不同,将患者分为老年髋臼骨折(年龄大于或等于60周岁)和年轻髋臼骨折(年龄小于60周岁)。评估老年髋臼骨折年发生率、及髋臼骨折患者年龄变化趋势,老年与年轻髋臼骨折患者合并其他损伤分布情况,老年与年轻髋臼骨折的损伤机制特点,老年与年轻髋臼骨折类型分布特点,及老年与年轻髋臼骨折影像学特征。结果:637例髋臼骨折中,老年髋臼骨折133例,年轻髋臼骨折504例。从1990年至2013年,老年髋臼骨折发生率显著增加,由1990年的6.7%增加到2013年的40.0%(p=0.021);髋臼骨折患者年平均年龄由1990年的(40.9±9.2)岁增加到2013年的(49.8±15.6)岁(p=0.045);从早期(1990~2000年)到后期(2001~2013年),老年患髋臼骨折发生率增加1.7倍(14.1%vs.24.1%,p=0.004)。老年髋臼骨折合并其他损伤的发生率明显低于年轻髋臼骨折(27.1%vs.48.8%,p=0.000)。老年髋臼骨折常见损伤机制为同一水平面的跌伤(即站立位高度跌伤),占36.1%,而年轻髋臼骨折跌伤所致者仅占0.2%(p=0.000)。老年患者前壁骨折(8.3%vs.1.0%,p=0.000)、前柱骨折(10.5%vs.4.8%,p=0.013)、前柱+后半横形骨折(3.8%vs.0.4%,p=0.005)发生率显著高于年轻患者。老年髋臼骨折除髋关节后脱位发生率显著低于年轻患者外(16.5%vs.31.9%,p=0.000),其他诸如方形区骨折(23.3%vs.3.2%,p=0.000)、海鸥征(21.1%vs.0.8%,p=0.000)、髋关节前脱位(21.8%vs.10.3%,p=0.000)、股骨头损伤(13.5%vs.4.6%,p=0.000)、粉碎性后壁骨折(10.5%vs.3.6%,p=0.001)、后壁边缘压缩性骨折(12.0%vs.3.2%,p=0.000)等影像学特征的发生率均显著高于年轻患者。结论:髋臼骨折中老年患者的比例以及髋臼骨折患者年龄均呈上升趋势;老年髋臼骨折合并其他损伤的发生率、损伤机制、骨折类型、影像学特征均与年轻患者不同。考虑到老年髋臼骨折常合并影响临床疗效的影像学特征,因此对于老年髋臼骨折,要根据骨折类型、影像学特征等情况作出最佳医疗决策,以便患者获得较满意的临床疗效。鉴于跌伤是导致老年髋臼骨折最常见原因,因此日常生活中要注意采取针对性措施,预防老年人跌倒事件发生。第二部分影响老年髋臼骨折手术疗效的因素分析目的:切开复位内固定治疗老年移位髋臼骨折的临床疗效还存在争论,并且认为如果老年髋臼骨折合并一些影像学特征,则预后较差。但是,何种特征是决定老年髋臼骨折术后疗效的关键因素,目前仍不清楚。因此,本研究旨在众多影响因素中,通过统计学分析,确定影响切开复位内固定治疗老年髋臼骨折预后的关键因素。方法:对1990年5月至2010年6月,因移位髋臼骨折采用切开复位内固定治疗的老年患者进行回顾性分析。按照一定的纳入与排除标准,共86例(86髋)患者纳入最终分析,其中男71例,女15例;手术时年龄60~90岁,平均(67.7±7.3)岁。术后骨折复位质量采用Matta's标准、临床功能的评估采用改良Merle D’Aubigne-Postel评分。根据既往文献报道,将骨折复位质量及以下6个影像学特征作为相关影响因素纳入分析,包括方形区骨折、海鸥征、髋关节后脱位、股骨头损伤、粉碎性后壁骨折及后壁边缘压缩性骨折。结果:随访时间2~198个月,平均39个月。末次随访时,髋臼骨折合并有上述6个影像学特征者,平均改良Merle D’Aubigne-Postel评分为(14.4±3.1)分;无这些影像学特征者,平均改良Merle D’Aubigne-Postel评分为(17.2±1.6)分。末次随访时,86例患者中,骨折解剖复位、复位不良及复位差者,平均改良Merle D’Aubigne-Postel评分分别为(16.8±2.4)分、(14.5±2.3)分及(11.3±1.4)分。多元逐步回归模型分析显示骨折复位质量(t=-10.45,p=0.000)、粉碎性后壁骨折(t=-2.74,p=0.008)及股骨头损伤(t=-3.51,p=0.000)是影响切开复位内固定治疗老年髋臼骨折预后的关键因素。结论:术前髋臼骨折合并后壁粉碎性骨折及股骨头损伤是影响切开复位内固定治疗老年髋臼骨折预后的独立危险因素;而术后骨折复位质量是切开复位内固定治疗老年髋臼骨折临床疗效的独立预测因素,如术后骨折能够获得解剖复位,则可预测患者术后疗效较满意。第三部分髋臼方形区骨折新型复位内固定器的研制与生物力学比较研究目的:尽管目前存在多种治疗髋臼方形区骨折的内固定器,但是对于骨质疏松性、粉碎性、及游离性方形区骨折的治疗仍存在挑战。本研究目的是评估我们自行设计的一种新的治疗髋臼方形区骨折的内固定器的生物力学特性,并将其与目前存在治疗方形区骨折的其他5种内固定器生物力学特性进行比较。方法:取第四代人工合成的半骨盆标本十具,并制作成单纯方形区骨折模型,将半骨盆固定在特制的夹具上,使髋臼开口水平向上,放置于英斯特朗E10000拉扭双轴电子万能材料力学试验机上,依次测试下述六种治疗髋臼方形区骨折内固定的生物力学特性:(1)单向铰链式髋臼钢板内固定(实验组),(2)L-形钢板内固定(L-形钢板组),(3)T-形钢板内固定(T-形钢板组),(4)H-形钢板内固定(H-形钢板组),(5)多向钛钢板内固定(多向钛钢板组),及(6)髂耻上缘长螺钉内固定(髂耻上缘长螺钉组)。生物力学特性采用以下4个因素来评估:各内固定在300 N载荷下的位移、使骨折位移2 mm和3 mm时所加载的力、及刚度。结果:实验组,在300 N载荷下骨折平均位移(2.3±0.2)mm、使骨折位移2 mm和3 mm时所加载的力分别为(220.2±49.0)N和(327.9±52.3)N、平均刚度为(119.9±21.1)N/mm。L-形钢板组,在300 N载荷下骨折平均位移(3.0±0.5)mm、使骨折位移2 mm和3 mm时所加载的力分别为(199.8±34.9)N和(310.0±46.0)N、平均刚度为(100.8±15.5)N/mm。T-形钢板组,在300 N载荷下骨折平均位移(3.4±0.2)mm、使骨折位移2 mm和3 mm时所加载的力分别为(138.4±20.7)N和(284.4±61.0)N、平均刚度为(78.5±12.6)N/mm。H-形钢板组,在300N载荷下骨折平均位移(3.2±0.7)mm、使骨折位移2 mm和3 mm时所加载的力分别为(206.6±56.4)N和(306.3±48.1)N、平均刚度为(100.4±24.3)N/mm。多向钛钢板组,在300 N载荷下骨折平均位移(1.7±0.3)mm、使骨折位移2 mm和3 mm时所加载的力分别为(395.2±107.7)N和(645.7±77.8)N、平均刚度为(192.1±43.1)N/mm。髂耻上缘长螺钉组,在300 N载荷下骨折平均位移(1.7±0.3)mm、使骨折位移2 mm和3 mm时所加载的力分别为(395.2±107.7)N和(645.7±77.8)N、平均刚度为(187.0±33.8)N/mm。在6组内固定中,比较使骨折位移2 mm和3 mm时所加载的力,发现多向钛钢板组和髂耻上缘长螺钉组显著高于其他4组(P0.05),而多向钛钢板组和髂耻上缘长螺钉组之间差异无统计学意义(P0.05);在剩下的4组中,T-形钢板组使骨折位移2 mm时的力,显著小于其他三组(P0.05),而其他三组之间差异无统计学意义(P0.05),但使骨折位移3 mm时的力,4组的差异无统计学意义(P0.05)。6组内固定中,比较当标本加载300 N载荷时的位移,发现相比其他组,髂耻上缘长螺钉组和多向钛钢板组位移最小(P0.05),实验组位移第二小(P0.05);而髂耻上缘长螺钉组和多向钛钢板组之间位移差异无统计学意义(P0.05),同时L-形钢板、T-形钢板、H-形钢板之间位移差异也无统计学意义(P0.05)。比较6种内固定刚度,发现髂耻上缘长螺钉组和多向钛钢板组刚度显著高于其他内固定组(P0.05),实验组刚度显著高于剩下的3组(P0.05),而T-形钢板组刚度最小(P0.05)。结论:在固定髋臼方形区骨折方面,髂耻上缘长螺钉和多向钛钢板具有最好的生物力学特性;单向铰链式髋臼钢板相比L-形钢板、T-形钢板、H-形钢板具有较好的生物力学特性。
[Abstract]:Part 1: epidemiological and clinical imaging features of acetabular fractures in the elderly: analysis of the epidemiological characteristics of acetabular fractures in the elderly, and comparison of the clinical and imaging features of the elderly and young acetabular fractures. Methods: a retrospective analysis of the clinical management of acetabular fractures in First Hospital Affiliated to Suzhou University from January 1990 to December 2013. Material. According to a certain inclusion and exclusion criteria, a total of 637 (637 hip) acetabular fractures were analyzed. According to the age of the patients, the patients were divided into elderly acetabular fractures (older than or equal to 60 years old) and young acetabular fractures (age less than 60 years old). The distribution of other injuries in the young acetabular fractures, the characteristics of the injury mechanism of the old and young acetabular fractures, the distribution characteristics of the old and young acetabular fractures, and the imaging characteristics of the old and young acetabular fractures. Results: in 637 cases of acetabular fractures, 133 cases of acetabular fracture, 504 cases of young acetabular fractures, from 1990 to 2013, The incidence of acetabular fractures in the aged increased significantly from 6.7% in 1990 to 40% in 2013 (p=0.021); the annual average age of acetabular fractures increased from (40.9 + 9.2) years (40.9 + 9.2) to 2013 (49.8 + 15.6) years (p=0.045); from early (1990~2000 years) to late (2001~2013 years), the incidence of acetabular fractures in the elderly increased by 1.7 times (14.1%vs.24.1%, P=0.004). The incidence of acetabular fracture with other injuries in the elderly was significantly lower than that of young acetabular fractures (27.1%vs.48.8%, p=0.000). The common mechanism for the injury of the aged acetabular fractures was the same level of fall (that is, a standing height fall), accounting for 36.1%, while only 0.2% (p=0.000) was caused by the fall of the young acetabular fracture (8.3%vs.1). The anterior wall fracture in the elderly (8.3%vs.1 .0%, p=0.000), the incidence of anterior column fracture (10.5%vs.4.8%, p=0.013), anterior column + posterior half transverse fracture (3.8%vs.0.4%, p=0.005) was significantly higher than that of young patients. The incidence of posterior dislocation of acetabular fracture in elderly patients was significantly lower than that of young patients (16.5%vs.31.9%, p=0.000), and other such as square fracture (23.3%vs.3.2%, p=0.000), seagull sign (21.1%vs.0.8%). P=0.000), the incidence of 21.8%vs.10.3% (p=0.000), femoral head injury (13.5%vs.4.6%, p=0.000), comminuted posterior wall fracture (10.5%vs.3.6%, p=0.001), posterior marginal compression fracture (12.0%vs.3.2%, p=0.000) were significantly higher than that of young patients. Conclusion: the proportion of the elderly patients with acetabular fractures and the acetabular bone The age of the fractured patients is on the rise; the incidence of the acetabular fracture with other injuries in the elderly, the mechanism of injury, the type of fracture, and the imaging features are different from those of the young patients. Considering the imaging features of the acetabular fracture in the elderly, the clinical effects are often combined, so the type of fracture and the imaging features of the aged hip fractures should be based on the characteristics of the fracture type and the imaging features. To make the best medical decision in order to get a satisfactory clinical effect. In view of the fall injury is the most common cause of the acetabular fracture in the elderly, we should take special measures to prevent the fall of the elderly in the daily life. The second part of the analysis of the factors affecting the curative effect of the aged acetabular fracture: open reduction and internal fixation There is still debate about the clinical efficacy of the treatment of the aged displaced acetabular fractures, and the prognosis is poor if the elderly acetabular fractures are associated with some imaging features. However, it is not clear what is the key factor in determining the postoperative effect of acetabular fractures in the elderly. Therefore, this study aims at many factors, through statistical credits. The key factors affecting the prognosis of senile acetabular fractures were determined by open reduction and internal fixation. Methods: from May 1990 to June 2010, the elderly patients with displaced acetabular fractures treated with open reduction and internal fixation were analyzed retrospectively. A total of 86 patients (86 hips) were included in the final analysis according to a certain inclusion and exclusion criteria, of which 71 were male. 15 women, 15 years old, average age (67.7 + 7.3) years old. The quality of fracture reduction was Matta's standard after operation. The modified Merle D 'Aubigne-Postel score was used to evaluate the clinical function. According to previous reports, the quality of fracture reduction and the following 6 imaging features were included in the analysis of the related factors, including the square fracture, Mi, posterior dislocation of the hip, femoral head injury, comminuted posterior wall fracture and compression fracture of the posterior wall. Results: the duration of follow-up was 2~198 months, averaging 39 months. At the last follow-up, the acetabular fracture combined with the above 6 imaging features, the average improved Merle D 'Aubigne-Postel score was (14.4 + 3.1), and none of these imaging features, The average improved Merle D 'Aubigne-Postel score was (17.2 + 1.6) scores. In the last follow-up, 86 patients with fracture anatomic reduction, poor reduction and poor reduction, the average improved Merle D' Aubigne-Postel score was (16.8 + 2.4), (14.5 + 2.3) and (11.3 + 1.4). Multivariate stepwise regression model analysis showed the quality of fracture reduction (t=-10.45 P=0.000), comminuted posterior wall fracture (t=-2.74, p=0.008) and femoral head injury (t=-3.51, p=0.000) are the key factors affecting the prognosis of senile acetabular fractures with open reduction and internal fixation. Conclusion: anterior acetabular fracture combined with posterior wall comminuted fracture and femoral head injury are independent outcome of open reduction and internal fixation in the treatment of the prognosis of acetabular fractures in the elderly The quality of postoperative fracture reduction is an independent predictor of the clinical efficacy of open reduction and internal fixation for the treatment of acetabular fractures in the elderly. If the postoperative fracture can be anatomic reduction, the prognosis of the patients can be predicted satisfactorily. The development of a new type of internal fixator for the third part of the acetabular area fracture and a comparative study of Biomechanics The objective of this study is to assess the biomechanical properties of a new type of internal fixator for the treatment of a square fracture of the acetabulum. The biomechanical properties of the other 5 kinds of internal fixers with square fracture were compared. Methods: Ten semi pelvic specimens of fourth generations of artificial pelvis were taken and a simple square fracture model was made. The half pelvis was fixed on the special fixture so that the level of the acetabular opening was upward and placed in the double axis electron of E10000. On the mechanical mechanical testing machine, the biomechanical properties of six kinds of internal fixation for the treatment of the square fracture of the acetabulum were tested in order: (1) the unidirectional hinge type acetabular plate internal fixation (experimental group), (2) L- shaped plate internal fixation (L- shaped plate group), (3) T- shaped plate internal fixation (T- shaped plate group), (4) H- shaped plate internal fixation (H- shaped plate group), and (5) multidirectional titanium plate Internal fixation (multiplate plate group) and (6) long iliac superior margin screw internal fixation (long iliac superior screw group). Biomechanical properties were assessed by the following 4 factors: displacement of internal fixation under 300 N load, force and stiffness of fracture displacement at 2 mm and 3 mm. Results: experimental group, the average displacement of fracture under 300 N load (2.3 + 0.2) Mm, the forces loaded on the fracture displacement 2 mm and 3 mm were respectively (220.2 + 49) N and (327.9 + 52.3) N, and the average stiffness was (119.9 + 21.1) N/mm.L- shaped steel plate group. The average displacement of the fracture was 3 + 0.5 mm under the load of 300 N, which made the fracture displacement 2 mm and 3 mm loaded as (199.8) N and (52.3) N. The average displacement of fracture was (3.4 + 0.2) mm under the load of 300 N, and the forces loaded at 2 mm and 3 mm were (138.4 + 20.7) N and (284.4 + 61) N respectively, and the average stiffness was (78.5 + 12.6) N/mm.H- shaped plate group. The average displacement of fracture was (3.2 + 0.7) mm under 300N load (3.2 + 0.7), which made the fracture displacement mm and mm. 206.6 + 56.4) N and (306.3 + 48.1) N, the average stiffness was (100.4 + 24.3) N/mm. multidirectional titanium plate group. The average displacement of fracture was (1.7 + 0.3) mm under 300 N load, and the force of the fracture displacement 2 mm and 3 mm was (395.2 + 107.7) N and (645.7 + 24.3) N respectively. The average stiffness was (mean) N/mm. iliac upper edge long screw group, and the fracture was fractured under N load. The average displacement (1.7 + 0.3) mm made the load of fracture displacement 2 mm and 3 mm respectively (395.2 + 107.7) N and (645.7 + 77.8) N respectively, and the average stiffness was (187 + 33.8) N/mm. in group 6, and the forces loaded during the fracture displacement 2 mm and 3 mm were compared, and the multidirectional titanium plate group and the iliac superior margin screw group were significantly higher than those of other groups (P0.05). There was no significant difference between the multidirectional titanium plate group and the long iliac superior margin screw group (P0.05). In the remaining 4 groups, the T- shaped plate group made the fracture displacement of 2 mM significantly less than the other three groups (P0.05), but the difference between the other three groups was not statistically significant (P0.05), but there was no statistical difference between the 4 groups when the fracture displacement was 3 mm (P0.0 5) in the internal fixation of group.6, the displacement of the specimens loaded with 300 N load was compared. It was found that the displacement of the long iliac superior margin screw group and the multidirectional titanium plate group was the least (P0.05), and the displacement of the experimental group was the second little (P0.05), while the difference of the displacement between the long screw group of the iliac upper edge and the multidirectional titanium plate group was not statistically significant (P0.05), and the L- shaped steel plate and T- shape were also found. The displacement difference between the steel plate and the H- shaped plate was not statistically significant (P0.05). Comparing the 6 internal fixation stiffness, it was found that the stiffness of the long iliac superior margin screw group and the multidirectional titanium plate group was significantly higher than the other internal fixation group (P0.05). The stiffness of the experimental group was significantly higher than the remaining 3 groups (P0.05), but the stiffness of the T- plate group was minimum (P0.05). Conclusion: in the fixed acetabular square. In the area of fracture, the long iliac upper edge screw and the multidirectional titanium plate have the best biomechanical properties, and the unidirectional hinged acetabular plate has better biomechanical properties than the L- steel plate, the T- steel plate and the H- shaped plate.

【学位授予单位】：苏州大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R687.3

【参考文献】