肩峰形态变异的临床意义及其对肩关节生物力学影响的有限元分析

发布时间：2018-06-20 23:45

本文选题：肩峰指数 + 肩峰侧倾角　；参考：《吉林大学》2015年博士论文

【摘要】：肩峰形态的变异一直被认为是导致肩袖损伤和盂肱关节炎发生的致病因素之一。诸多学者通过大量研究，对肩峰形态的变异以及其与疾病之间联系的认识不断深入。用以描述肩峰形态变异的影像学方法应运而生，其临床意义也在不断得到认识。目前，国内外学者对肩峰指数、肩峰侧倾角、决定性肩角与肩关节疾病相关联系的研究在不断深入。诸多学者认为这些指标可以作为临床医生诊断疾病的辅助临床参数。以往的临床研究，都是研究肩峰某一种形态的变异与某一种疾病之间的联系。但是，如果这些变异同时出现在同一病人身上，即该患者的肩峰同时具有两种甚至更多的特点：比如其肩峰指数较大，同时肩峰侧倾角又很小，那么其对于疾病的发展是协同作用还是拮抗作用？如果是协同作用，哪一种变异起到的危害更大些？目前还鲜有报道。本研究旨在探讨肩峰指数、肩峰侧倾角、决定性肩角与肩关节疾病之间的联系以及研究这些参数之间的内在规律，并通过计算机数值仿真分析对其相关的问题进行验证，为治疗此类疾病提供部分生物力学理论基础。本研究共分为临床研究和计算机数值仿真分析两部分。第一部分：肩峰指数联合肩峰侧倾角的临床研究。本研究的目的是通过一项临床研究，来分析肩峰指数、肩峰侧倾角与肩袖撕裂和肩关节急性创伤之间的联系。我们利用标准肩关节真正前后X像来测量同一患者的肩峰指数和肩峰侧倾角。肩峰指数和肩峰侧倾角的测量来自于三组病例：肩关节急性创伤组共收录61名患者，肩袖撕裂组共收录165名患者，健康对照组共收录63名患者。研究结果显示：肩袖撕裂组的平均肩峰指数为0.72±0.06，平均肩峰侧倾角76.8°±7.02；急性肩关节损伤组平均肩峰指数0.59±0.05，平均肩峰侧倾角84.4°±7.99；健康对照组肩峰指数为0.65±0.06；平均肩峰侧倾角80.2°±7.32。各组之间肩峰指数及肩峰侧倾角具有统计学意义（p0.01）。有意思的是，该研究结果首次发现，各组的肩峰指数和肩峰侧倾角均存在一种反比例关系，即：肩峰向侧方的延展度越大，肩峰向下方的倾斜度也就越大；相反，肩峰向侧方的延展度越小，肩峰向下方的倾斜度也就越小。这一规律说明，肩峰指数和肩峰侧倾角在导致肩袖撕裂的过程中起到协同作用。学者Nyffeler认为小肩峰指数可能是导致盂肱关节炎的重要发病因素，但是在这部分研究中，我们没有发现小肩峰指数与盂肱关节之间存在联系。但是我们发现在因急性肩关节创伤的患者中，其平均肩峰指数明显小于对照组，因此我们推论：由于肩峰指数小、肩峰侧倾角较大，从而导致肩峰对其下方肱骨头的包容度减小，虽然关节灵活性好，但是稳定性较差；相反，肩峰指数大、肩峰侧倾角较小，会增加肩峰对其下方肱骨头的包容度，因此关节稳定性增加但灵活性降低。第二部分：肩峰指数联合肩峰侧倾角及决定性肩角的临床研究。我们利用标准肩关节真正前后X像来同时测量同一个患者的肩峰指数、肩峰侧倾角、决定性肩角。该研究收录两组病例：肩袖撕裂患者组共计105人；健康人群对照组共计62人。研究结果显示：肩袖撕裂患者组的平均决定性肩角为36.2°±4.61；平均肩峰指数为0.71±0.05；平均肩峰侧倾角为77.2°±5.94。健康对照组的平均决定性肩角为31.7°±5.03；平均肩峰指数为0.64±0.06；平均肩峰侧倾角为82.0°±7.53。各组的参数具有统计学意义（p0.01）。通过相关性分析发现，两组人群的肩峰形态存在以下规律：肩峰指数与肩峰侧倾角呈反比；肩峰指数与决定性肩角呈正比。我们称这一规律为“肩峰规律”。由于这一规律的发现，我们证明肩峰向侧方的延展度增加，势必会导致其向下方的倾斜度增加，在导致肩袖撕裂的病因中二者起到一种协同作用，但人类的肩峰形态为何会发育成如此，尚不得而知。第三部分：肩关节三维有限元模型的建立，及不同形态的肩峰撞击的有限元分析。首先建立肩袖撕裂患者和正常的健康人的两组肩关节模型。利用患者及志愿者的CT数据，通过Mimics软件建立肩胛骨、肱骨的三维几何模型。由于CT建立的模型其初始位置受到患者的体位的影响，因此，为了准确测量肩峰指数、肩峰侧倾角、决定性肩角，将三维模型的位置统一调整。然后分别在每例模型上测量以上参数，然后选取一例肩袖撕裂患者的和一例健康人的肩关节模型。进一步建立冈上肌肌腱、和盂肱关节软骨的三维几何模型，利用Geomagic Studio优化模型后，导入Abaqus软件，赋予各个部位材料属性，随后在肩胛骨平面做外展撞击的模拟计算。从而分析不同肩峰形态的肩关节在肩胛骨平面外展时，当肩峰与其下方的软组织发生接触后肌腱和盂肱关节软骨之间VonMises应力及应变情况。结果表明：肩袖撕裂模型外展撞击后在肌腱与肩峰之间产生的应力为172.6MPa（平均12.53MPa），明显大于健康人模型的42.99MPa（平均5.108MPa），说明肩袖撕裂模型会在肌腱处产生较明显的应力集中。肩袖撕裂模型外展撞击后在肱骨头与肩胛盂软骨之间产生的应力为69.91MPa（平均16.06MPa）大于健康人模型的53.41MPa（平均12.61MPa），该实验结果证明在外展撞击时肩袖撕裂模型在盂肱关节之间产生的应力高于正常人模型。第四部分：前肩峰成形术的虚拟手术及有限元分析。目前临床上治疗肩峰下撞击的一种主要术式是采用关节镜进行前肩峰下成形术，该手术通过修改肩峰前外侧下方骨皮质的形态，从而缓解肩峰前部撞击的发生。但是该手术是否可以缓解肩关节在肩胛骨平面外展时所产生的撞击尚缺少相关生物力学研究。选取第三章中的肩袖撕裂模型在Magics软件中使用多段线切割功能（Polyline Cut）进行虚拟手术模拟前肩峰成形术。从肩袖撕裂模型的肩峰前部向后画出2.5cm区域的范围，将该区域内的肩峰下方骨皮质磨除；然后将肩峰前部8mm的骨质切除掉。通过该手术后CT肩峰指数为0.60，CT肩峰侧倾角为82.71°，CT决定性肩角为28.56°，由此可以看出该手术方式并不能改变肩峰的外侧缘形态。同时，外展该模型的肱骨使之达到肩峰撞击的位置并进行有限元分析。结果显示，通过计算后发现其外展撞击后在肌腱与肩峰之间产生的最大应力为81.59MPa（平均6.658MPa），相对于肩袖撕裂模型在肌腱处产生的应力有所减小，但和正常人的模型相比较，依然有较大的应力集中。第五部分：肩峰外侧缘虚拟切除手术及有限元分析。从前一部分可以发现，前肩峰成形术能够改善肩袖撕裂模型的在肩峰与肌腱之间产生的应力集中，但是治疗效果仍有欠缺。因此，我们根据肩峰的生理解剖结构提出一种肩峰外侧缘切除术的设想。在第三部分肩袖撕裂模型的基础上，在Magics软件中使用多段线切割功能能将肩峰骨皮质的最外侧缘由前向后均匀的切除一部分，切除的骨量没有固定数值，目标是切除骨皮质后使该模型的肩峰指数、肩峰侧倾角、决定性肩斜角与健康人模型基本保持一致。经过测量切除后的模型其CT肩峰指数为0.45，CT肩峰侧倾角为86.25°，CT决定性肩角为22.48°，各参数与健康人模型基本一致。有限元分析结果显示外展撞击后肌腱与肩峰之间产生的最大应力减小到75.01MPa（平均6.025MPa），可见该方法通过修改肩峰形态，可以最大程度效缓解肩峰外侧缘产生的撞击。我们发现盂肱关节软骨的应力减小为43.81MPa（平均12.74MPa），这是一个有趣的现象，肩峰指数减小后在撞击时盂肱关节内的应力却减小，这一点和Nyffyler的假设相反，也就是说盂肱关节内的压力并没有因为肩峰指数的缩小而增加。通过上述研究我们认为，肩峰向侧方的延展度及向下方的倾斜度过大与肩袖撕裂密切相关，肩峰向侧方的延展度及向下方的倾斜度过小则有可能是导致肩关节容易罹患急性损伤的原因，而这些形态变异与盂肱关节炎的发生发展没有必然联系。肩峰指数、肩峰侧倾角、决定性肩角可以作为临床诊断上述疾病的辅助指标。该研究通过有限元分析发现，肩袖撕裂患者在肩胛骨平面外展肩关节时，肌腱会产生较明显的应力集中，前肩峰成形术可以缓解该处的应力集中，但效果有限，如果可以将肩峰外侧缘切除至正常人范围，则可以更大程度上缓解外展肩关节时肌腱与肩峰的应力集中。但这只是通过生物力学研究后的一种结论，距离投入临床实践还有很多问题需要解决。
[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.
【学位授予单位】：吉林大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R684

【共引文献】