全髋关节置换术假体位置的生物力学研究及临床应用
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摘要
在全髋关节置换术中，髋臼与股骨柄假体的定位对术后假体使用寿命和关节功能具有重要影响。目前，国内外学者对不同髋臼杯前倾角、外展角和股骨柄前倾角下，髋关节的生物力学情况和临床疗效进行了一些研究。随着研究的进展，学术界提出了联合前倾技术，即兼顾髋臼杯与股骨柄假体的前倾角，使二者之和维持在25°-50°之间，其中以35°的临床效果最为优良。尽管此种技术已经有了一定的临床报导，但联合前倾技术的生物力学特性目前还鲜有报道。本研究旨在探讨利用不同的联合前倾技术进行全髋关节置换术后，髋关节周围骨性结构及植入假体的应力和应变特点，并通过临床研究对其进行验证，为此项技术提供生物力学基础理论，便于此技术在临床的进一步应用。本研究共分为计算机有限元分析、尸体生物力学实验和临床研究三部分。
第一部分：全髋关节置换术联合前倾角技术的有限元分析。本研究的主要目的是探讨不同联合前倾角技术对髋关节假体的生物力学特性的影响。利用志愿者CT建立骨盆有限元模型，根据联合前倾角技术的基础理论，利用不同六种联合前倾技术进行全髋关节置换术，即股骨柄前倾0°、5°、10°、15°、20°和25°，分别联合髋臼杯前倾35°、30°、25°、20°、15°和10°。在以上所有模型中，髋臼杯的外展角均为40°。给予一定的力学加载。从理论上分析不同的联合前倾状态下骨盆位移、髋臼、髋臼杯、臼杯内衬、陶瓷头、股骨柄假体及股骨的峰值Von Mises应力。结果表明股骨柄前倾20°联合臼杯前倾15°技术最为理想，因为这种技术可以在最大限度上避免髋臼周缘、髋臼杯、内衬、陶瓷头、股骨柄、股骨中段皮质的应力集中的出现，降低了假体或骨骼发生疲劳断裂的概率，减少了摩擦界面的摩擦力和人工关节固定界面的机械性失败的可能性。此外，这种技术能在最大层面上减少骨盆在矢状面或冠状面上的分离移动，使骨盆最为接近其生理状态下的力学分布状态。
第二部分：全髋关节置换术中联合前倾角技术的尸体生物力学研究：本研究的目的研究比较联合前倾技术对全髋关节术后骨性结构的应变影响，并与有限元模拟结果进行相互验证。应用三种联合前倾角技术对尸体进行全髋关节置换术，即股骨柄前倾0°-10°、11°-20°和21°-25°，分别联合臼杯前倾35-25°、24°-15°和14°-10°。髋臼杯外展角设计范围为35°-45°。在600N载荷下，通过电阻应变片技术测量股骨柄周缘骨皮质和髋臼前后壁的应变情况，并与正常加载模式下的应变进行比较。结果表明与其他两种联合前倾技术相比，股骨柄前倾11-20°联合臼杯前倾24°-15°是一种合理的联合前倾技术，因为其股骨表面应变与自然状态下最为接近，而在髋臼周缘体现出了最小的应变率。这个结果与有限元分析的结果比较，具有一定的相似性。两个实验达到了彼此验证，互为补充的目的。
第三部分：全髋关节置换术中联合前倾角技术的临床研究：结合前两项实验的研究结果，进行临床研究设计。利用三种联合前倾技术进行全髋关节置换术，即股骨柄前倾0°-10°、11°-20°和21°-25°，分别联合臼杯前倾35-25°、24°-15°和14°-10°。髋臼杯外展角为40°左右。术前、术后分别对其影像学疗效进行评估，评价指标主要包括术后患肢重力臂、偏心距、旋转中心高度和沈通线的连续性进行评估；同时应用电话随访确定患者术后半年内出现的并发症及生存情况，利用Harris评分对关节术后功能进行评价分析。我们发现股骨柄前倾0-10°联合髋臼杯前倾35°-25°技术、股骨柄前倾11°-20°联合髋臼杯前倾24°-15°技术和股骨柄前倾21°-25°联合髋臼杯前倾14°-10°三种联合前倾技术可以用于治疗股骨颈骨折、股骨头缺血坏死、发育性髋臼发育不良和骨性关节炎，主要体现在患肢术后的重力臂、股骨偏心距和旋转高度和沈通线的连续性得到了纠正。术后半年关节功能的Harris评分为良。三种联合前倾技术的短期临床疗效未见显著差异。
通过上述研究我们认为，在联合前倾角为35°的技术中，股骨柄前倾20°联合臼杯前倾15°技术是一种理想的全髋关节置换技术。它不仅可以避免关节假体周围出现显著的应力集中情况，降低假体断裂的风险，减少摩擦界面的摩擦力，预防关节过度磨损，在髋臼周缘和股骨中上段产生较小的应变，使骨盆接近生理状态的力学分布情况；同时可以用于治疗股骨颈骨折、股骨头缺血坏死等疾病，并在临床影像、术后并发症和术后短期的关节功能方面取得了满意的效果。
The positioning of acetabular component and femoral stem is playing an important rolein total hip arthroplasty (THA) for recovery of hip function or releasing of pain. Many studieson the hip biomechanics and clinical outcome of THA have been published, in which variablestem or acetabular anteversion and inclination were still controversial. A combinedanteversion technique (CAT) is a new concept, which was proposed by Professor ChristopherAmuwa from Nigeria in2008. Combined anteversion technique considered35°as an optimalsum of stem and cup, which ranging from25°-50°. Although some clinical trials ofcombined anteversion technique have been reported, the biomechanical properties of this skillare still unknown. The main purpose of the present research is to explore the strain and stressof hip bone or prosthesis after total hip arthroplasty with different combined anteversiontechnique. Clinical trials were designed and performed according to the basic researchoutcome. The present research consists of three major parts, finite element analysis, cadaver tests andclinical trials, aiming to provide biomechanical basic theories and evidence for further clinicalapplications.
The first section is the finite element analysis of combined anteversion technique in THA.The objective of the study is to explore the biomechanical traits of hip prosthesis after totalhip replacement with combined anteversion technique. A pelvic three-dimensional model wasestablished based on computer-tomography scanning data. Six virtual total hip arthroplastywere performed by this advanced surgery. The stem anteversions were settled as0°,5°,10°,15°,20°and25°, which combined with the cup anteversion of35°,30°,25°,20°,15°and10°,respectively. The inclination of acetabular component is designed for40°in all the six models.The pelvic movement and peak Von Mises stress of acetabular component, prosthetic cup,ceramic liner, femoral head, femoral stem or cortical bone were evaluated after virtualsurgeries. The results showed that stem anteverted20°combined with cup anteverted15°skillis an optimal technique, because it could protect against stress concentration on hip bone, cup, liner, femoral head, prosthetic stem and cortical bone maximatily. It could decrease thepossibility of prosthetic fatigue break and friction between cup liner and femoral head. Inaddition, a slight pelvic internal movement could ensure the physiological status utmost whenthe hip is loaded.
The second section is the cadaver tests of combined anteversion technique in THA. Theaim of the study is to explore the strain of hip or femoral bone after THA with CAT andprovide a mutual verification with the above computer simulation. Three techniques wereused in the present study. The stem were anteverted0°-10°,11°-20°and21°-25°, combiningwith cup antervsersion of35°-25°,24°-15°and14°-10°, respectively. The cup inclinationranged from35°to45°. The strain of posterior or anterior wall of acetabula and femoralperipheric cortical bone was compared with normal hip after loading by600N forces.Compared with the other two skills, stem anteverted11°-20°combined with cup24°-15°is areasonable technique, due to its slight change strain of femoral cortical bone and acetabularelative to normal hip. The present result is similar to the results of finite element analysis tosome extent, by which a mutual verification was addressed.
The final section of the present research is the clinical trial of combined anteversiontechnique in THA. According to the results of the above two investigations, three combinedanteversion techniques were used in the clinical trial, in which stem anteverted0°-10°,11°-20°and21°-25°, combining with cup antervsersion of35°-25°,24°-15°and14°-10°,respectively. The cup inclination was addressed at40°in THA procedure. The radiographicresults were estimated pre-or postoperatively, including moment arm of gravity, femoraloffset, height of rotation center and continuity of shenton’s line. All the patients werefollowed up for postoperative complications by telephone communication. In addition, Harrisscoring system was performed to estimate the hip function. We found that femoral neckfracture, avascular necrosis of femoral head, developmental dysplasia or hip arthritis could betreated by these three kinds of surgical skills. The poor moment arm of gravity, femoral offset,height of rotation center and shenton’s continuity were improved after THA. All the hips showed a good function after six months postoperatively, whereas there was no significantdifference between all the three combined anteversion techniques.
According to the three investigations, stem anteverted20°combined with cup anteverted15°is considered as a suitable CAT in the research of combined anteversion of35°. It couldavoid excess stress concentration on prosthesis or bone, which could decrease the prostheticfatigue break and friction. In addition, this technique could not only certify the similarphysiological situation paralleled to normal pelvis, but also provided a good outcome ofradiology, postoperative complications and hip function.
第一部分：全髋关节置换术联合前倾角技术的有限元分析。本研究的主要目的是探讨不同联合前倾角技术对髋关节假体的生物力学特性的影响。利用志愿者CT建立骨盆有限元模型，根据联合前倾角技术的基础理论，利用不同六种联合前倾技术进行全髋关节置换术，即股骨柄前倾0°、5°、10°、15°、20°和25°，分别联合髋臼杯前倾35°、30°、25°、20°、15°和10°。在以上所有模型中，髋臼杯的外展角均为40°。给予一定的力学加载。从理论上分析不同的联合前倾状态下骨盆位移、髋臼、髋臼杯、臼杯内衬、陶瓷头、股骨柄假体及股骨的峰值Von Mises应力。结果表明股骨柄前倾20°联合臼杯前倾15°技术最为理想，因为这种技术可以在最大限度上避免髋臼周缘、髋臼杯、内衬、陶瓷头、股骨柄、股骨中段皮质的应力集中的出现，降低了假体或骨骼发生疲劳断裂的概率，减少了摩擦界面的摩擦力和人工关节固定界面的机械性失败的可能性。此外，这种技术能在最大层面上减少骨盆在矢状面或冠状面上的分离移动，使骨盆最为接近其生理状态下的力学分布状态。
第二部分：全髋关节置换术中联合前倾角技术的尸体生物力学研究：本研究的目的研究比较联合前倾技术对全髋关节术后骨性结构的应变影响，并与有限元模拟结果进行相互验证。应用三种联合前倾角技术对尸体进行全髋关节置换术，即股骨柄前倾0°-10°、11°-20°和21°-25°，分别联合臼杯前倾35-25°、24°-15°和14°-10°。髋臼杯外展角设计范围为35°-45°。在600N载荷下，通过电阻应变片技术测量股骨柄周缘骨皮质和髋臼前后壁的应变情况，并与正常加载模式下的应变进行比较。结果表明与其他两种联合前倾技术相比，股骨柄前倾11-20°联合臼杯前倾24°-15°是一种合理的联合前倾技术，因为其股骨表面应变与自然状态下最为接近，而在髋臼周缘体现出了最小的应变率。这个结果与有限元分析的结果比较，具有一定的相似性。两个实验达到了彼此验证，互为补充的目的。
第三部分：全髋关节置换术中联合前倾角技术的临床研究：结合前两项实验的研究结果，进行临床研究设计。利用三种联合前倾技术进行全髋关节置换术，即股骨柄前倾0°-10°、11°-20°和21°-25°，分别联合臼杯前倾35-25°、24°-15°和14°-10°。髋臼杯外展角为40°左右。术前、术后分别对其影像学疗效进行评估，评价指标主要包括术后患肢重力臂、偏心距、旋转中心高度和沈通线的连续性进行评估；同时应用电话随访确定患者术后半年内出现的并发症及生存情况，利用Harris评分对关节术后功能进行评价分析。我们发现股骨柄前倾0-10°联合髋臼杯前倾35°-25°技术、股骨柄前倾11°-20°联合髋臼杯前倾24°-15°技术和股骨柄前倾21°-25°联合髋臼杯前倾14°-10°三种联合前倾技术可以用于治疗股骨颈骨折、股骨头缺血坏死、发育性髋臼发育不良和骨性关节炎，主要体现在患肢术后的重力臂、股骨偏心距和旋转高度和沈通线的连续性得到了纠正。术后半年关节功能的Harris评分为良。三种联合前倾技术的短期临床疗效未见显著差异。
通过上述研究我们认为，在联合前倾角为35°的技术中，股骨柄前倾20°联合臼杯前倾15°技术是一种理想的全髋关节置换技术。它不仅可以避免关节假体周围出现显著的应力集中情况，降低假体断裂的风险，减少摩擦界面的摩擦力，预防关节过度磨损，在髋臼周缘和股骨中上段产生较小的应变，使骨盆接近生理状态的力学分布情况；同时可以用于治疗股骨颈骨折、股骨头缺血坏死等疾病，并在临床影像、术后并发症和术后短期的关节功能方面取得了满意的效果。
The positioning of acetabular component and femoral stem is playing an important rolein total hip arthroplasty (THA) for recovery of hip function or releasing of pain. Many studieson the hip biomechanics and clinical outcome of THA have been published, in which variablestem or acetabular anteversion and inclination were still controversial. A combinedanteversion technique (CAT) is a new concept, which was proposed by Professor ChristopherAmuwa from Nigeria in2008. Combined anteversion technique considered35°as an optimalsum of stem and cup, which ranging from25°-50°. Although some clinical trials ofcombined anteversion technique have been reported, the biomechanical properties of this skillare still unknown. The main purpose of the present research is to explore the strain and stressof hip bone or prosthesis after total hip arthroplasty with different combined anteversiontechnique. Clinical trials were designed and performed according to the basic researchoutcome. The present research consists of three major parts, finite element analysis, cadaver tests andclinical trials, aiming to provide biomechanical basic theories and evidence for further clinicalapplications.
The first section is the finite element analysis of combined anteversion technique in THA.The objective of the study is to explore the biomechanical traits of hip prosthesis after totalhip replacement with combined anteversion technique. A pelvic three-dimensional model wasestablished based on computer-tomography scanning data. Six virtual total hip arthroplastywere performed by this advanced surgery. The stem anteversions were settled as0°,5°,10°,15°,20°and25°, which combined with the cup anteversion of35°,30°,25°,20°,15°and10°,respectively. The inclination of acetabular component is designed for40°in all the six models.The pelvic movement and peak Von Mises stress of acetabular component, prosthetic cup,ceramic liner, femoral head, femoral stem or cortical bone were evaluated after virtualsurgeries. The results showed that stem anteverted20°combined with cup anteverted15°skillis an optimal technique, because it could protect against stress concentration on hip bone, cup, liner, femoral head, prosthetic stem and cortical bone maximatily. It could decrease thepossibility of prosthetic fatigue break and friction between cup liner and femoral head. Inaddition, a slight pelvic internal movement could ensure the physiological status utmost whenthe hip is loaded.
The second section is the cadaver tests of combined anteversion technique in THA. Theaim of the study is to explore the strain of hip or femoral bone after THA with CAT andprovide a mutual verification with the above computer simulation. Three techniques wereused in the present study. The stem were anteverted0°-10°,11°-20°and21°-25°, combiningwith cup antervsersion of35°-25°,24°-15°and14°-10°, respectively. The cup inclinationranged from35°to45°. The strain of posterior or anterior wall of acetabula and femoralperipheric cortical bone was compared with normal hip after loading by600N forces.Compared with the other two skills, stem anteverted11°-20°combined with cup24°-15°is areasonable technique, due to its slight change strain of femoral cortical bone and acetabularelative to normal hip. The present result is similar to the results of finite element analysis tosome extent, by which a mutual verification was addressed.
The final section of the present research is the clinical trial of combined anteversiontechnique in THA. According to the results of the above two investigations, three combinedanteversion techniques were used in the clinical trial, in which stem anteverted0°-10°,11°-20°and21°-25°, combining with cup antervsersion of35°-25°,24°-15°and14°-10°,respectively. The cup inclination was addressed at40°in THA procedure. The radiographicresults were estimated pre-or postoperatively, including moment arm of gravity, femoraloffset, height of rotation center and continuity of shenton’s line. All the patients werefollowed up for postoperative complications by telephone communication. In addition, Harrisscoring system was performed to estimate the hip function. We found that femoral neckfracture, avascular necrosis of femoral head, developmental dysplasia or hip arthritis could betreated by these three kinds of surgical skills. The poor moment arm of gravity, femoral offset,height of rotation center and shenton’s continuity were improved after THA. All the hips showed a good function after six months postoperatively, whereas there was no significantdifference between all the three combined anteversion techniques.
According to the three investigations, stem anteverted20°combined with cup anteverted15°is considered as a suitable CAT in the research of combined anteversion of35°. It couldavoid excess stress concentration on prosthesis or bone, which could decrease the prostheticfatigue break and friction. In addition, this technique could not only certify the similarphysiological situation paralleled to normal pelvis, but also provided a good outcome ofradiology, postoperative complications and hip function.
引文
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