短与长髓内钉治疗不稳定粗隆下骨折的有限元分析
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摘要
[目的]对长、短型髓内钉治疗Seinsheimer V型不稳定骨折进行有限元分析,为临床提供生物力学证据。[方法]三维重建Sawbones股骨模型,制备包含四部分骨折块且有20 mm范围内侧缺损的粗隆下骨折模型。制作长、短髓内钉模型。将模型进行匹配、网格划分、赋值属性等有限元分析前处理。装配、定义接触面、边界条件、载荷设置,进行有限元分析。[结果]随着外力增加长钉以及短钉治疗下各组参考指标均呈线性增长,差异有统计学意义(P<0.001)。2 000 N载荷下,短钉组近端骨块最小位移显著小于长钉组[(16.397±0.044) mm vs(17.210±0.044)mm,P<0.001],短钉组近端骨块最大位移也显著小于长钉组[(28.578±0.020) mm vs(31.171±0.013) mm,P<0.001。此外,短钉组近端骨折线缝隙显著小于长钉组[(1.396±0.074) mm vs(1.798±0.052) mm,P<0.001],短钉组外侧骨折线缝隙显著小于长钉组[(0.525±0.012) mm vs(0.755±0.017) mm,P<0.001]。[结论]短髓内钉较长髓内钉有更佳的控制骨折块移动和对骨折块的把持力,应做为股骨粗隆下骨折内固定的首选。
[Objective] To explore the biomechanical characteristics of short versus long intramedullary nail for fixation of Seinsheimer type V subtrochanteric fractures, and provide biomechanical evidence to the clinical practice. [Methods] A 3-D reconstruction model was created by using the Sawbones, and then mimic four-part subtrochanteric fractures were conducted with UG software, which included a wedge with a 20-mm medial defect to simulate loss of the medial calcar. After pre-processing,including model matching, meshing, as well as assigning properties, interfaces and loading, the finite element analysis were conducted. [Results] Along with increase of loading, the fragmental displacements and fracture voids significantly increased in both the short nail group and long nail group(P<0.001). Under 2000 N loads, the minimal displacement of proximal fracture fragment proved significantly less in the short nail group than that in the long nail group [(16.397±0.044) mm versus(17.210±0.044) mm versus, P<0.001], consistently, the maximal displacement of proximal fracture fragment was of [(28.578 ± 0.020) mm versus(31.171±0.013) mm, P<0.001]. In addition, the proximal fracture void in the short nail proved significantly less than that in the long nail group [(1.396±0.074) mm versus(1.798±0.052) mm. P<0.001], similarly the lateral fracture void in the short nail group was significantly less than the long nail group [(0.525±0.012) mm versus 0.755±0.017) mm, P<0.001]. [Conclusion] The short intramedullary nail with advantages of better bone fragment holding, and higher capacity to restrain fragment micro-motion than the long intramedullary nail, should be the first choice for internal fixation of subtrochanteric fractures.
[Objective] To explore the biomechanical characteristics of short versus long intramedullary nail for fixation of Seinsheimer type V subtrochanteric fractures, and provide biomechanical evidence to the clinical practice. [Methods] A 3-D reconstruction model was created by using the Sawbones, and then mimic four-part subtrochanteric fractures were conducted with UG software, which included a wedge with a 20-mm medial defect to simulate loss of the medial calcar. After pre-processing,including model matching, meshing, as well as assigning properties, interfaces and loading, the finite element analysis were conducted. [Results] Along with increase of loading, the fragmental displacements and fracture voids significantly increased in both the short nail group and long nail group(P<0.001). Under 2000 N loads, the minimal displacement of proximal fracture fragment proved significantly less in the short nail group than that in the long nail group [(16.397±0.044) mm versus(17.210±0.044) mm versus, P<0.001], consistently, the maximal displacement of proximal fracture fragment was of [(28.578 ± 0.020) mm versus(31.171±0.013) mm, P<0.001]. In addition, the proximal fracture void in the short nail proved significantly less than that in the long nail group [(1.396±0.074) mm versus(1.798±0.052) mm. P<0.001], similarly the lateral fracture void in the short nail group was significantly less than the long nail group [(0.525±0.012) mm versus 0.755±0.017) mm, P<0.001]. [Conclusion] The short intramedullary nail with advantages of better bone fragment holding, and higher capacity to restrain fragment micro-motion than the long intramedullary nail, should be the first choice for internal fixation of subtrochanteric fractures.
引文
[1]Jiang LS,Shen L,Dai LY.Intramedullary fixation of subtrochanteric fractures with long proximal femoral nail or long gamma nail:technical notes and preliminary results[J].Ann Acad Med Singapore,2007,36(10):821-826.
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[3]JC K,The laws of bone architecture[J].Am J Anat,1917,21:177-198.
[4]Craig NJ,Sivaji C,Maffulli N.Subtrochanteric fractures.a review of treatment options[J].Bull Hosp Jt Dis,2001,60(1):35-46.
[5]de Vries JS.Treatment of subtrochanteric nonunions[J].Injury,2006,37(2):203-211.
[6]Sims SH.Subtrochanteric femur fractures[J].Orthop Clin North Am,2002,33(1):113-126.
[7]Parker MJ,Handoll HH.Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults[J].Cochrane Database Syst Rev,2010,(9):Cd000093.
[8]王宗仁,罗先正,刘长贵.GAMMA钉在粗隆间骨折的临床应用[J].中国骨与关节损伤杂志,1996,(1):12-14.
[9]张保中.股骨转子周围骨折的髓内钉固定[J].中华创伤骨科杂志,2002,4(3):192-194.
[10]Hong CC.The long and short of cephalomedullary nails in the treatment of osteoporotic pertrochanteric fracture[J].Singapore Med J,2017,58(2):85-91.
[11]Li Z.Short versus long intramedullary nails for the treatment of intertrochanteric hip fractures in patients older than 65 years[J].Int J Clin Exp Med,2015,8(4):6299-6302.
[12]Raval P.Comparison of short vs long anti-rotation in treating trochanteric fractures[J].Malays Orthop J,2016,10(1):22-28.
[13]Zhang Y.Long and short intramedullary nails for fixation of intertrochanteric femur fractures(OTA 31-A1,A2 and A3):A systematic review and meta-analysis[J].Orthop Traumatol Surg Res,2017,103(5):685-690.
[14]Okcu G.Which implant is better for treating reverse obliquity fractures of the proximal femur:a standard or long nail[J].Clin Orthop Relat Res,2013,471(9):2768-2775.
[15]Boone C.Short versus long intramedullary nails for treatment of intertrochanteric femur fractures(OTA 31-A1 and A2)[J].J Orthop Trauma,2014,28(5):96-100.
[16]Brekelmans WA,Poort HW,Slooff TJ.A new method to analyse the mechanical behaviour of skeletal parts[J].Acta Orthop Scand,1972,43(5):301-317.
[17]Papini M.The biomechanics of human femurs in axial and torsional loading:comparison of finite element analysis,human cadaveric femurs,and synthetic femurs[J].J Biomech Eng,2007,129(1):12-19.
[18]Kuzyk PR.A biomechanical comparison of static versus dynamic lag screw modes for cephalomedullary nails used to fix unstable peritrochanteric fractures[J].J Trauma Acute Care Surg,2012,72(2):65-70.
[19]Seinsheimer F.Subtrochanteric fractures of the femur[J].J Bone Joint Surg Am,1978,60(3):300-306.
[20]Frisch NB.Short versus long cephalomedullary nails for pertrochanteric hip fracture[J].Orthopedics,2017,40(2):83-88.
[21]Marmor M.Biomechanical comparison of long,short,and extended-short nail construct for femoral intertrochanteric fractures[J].Injury,2015,46(6):963-969.
[22]Winiowskj A.Nonunion following intramedullary nailing of the femur with and without reaming.Results of a multicenter randomized clinical trial[J].J Bone Joint Surg Am,2003,85-a(11):2093-2096.
[23]陈贵新,沈学律.PFN结合早期功能锻炼治疗粗隆间骨折及粗隆下骨折[J].中国伤残医学,2011,(5):36-37.
[24]Gardner MP.Mechanical evaluation of large-size fourth-generation composite femur and tibia models[J].Ann Biomed Eng,2010,38(3):613-620.
[25]Eberle S.Auxiliary locking plate improves fracture stability and healing in intertrochanteric fractures fixated by intramedullary nail[J].Clin Biomech(Bristol,Avon),2012,27(10):1006-1010.
[2]Zhang,Y.Clincial epidemiology of orthopedic trauma[M].Thieme,2012:157-177.
[3]JC K,The laws of bone architecture[J].Am J Anat,1917,21:177-198.
[4]Craig NJ,Sivaji C,Maffulli N.Subtrochanteric fractures.a review of treatment options[J].Bull Hosp Jt Dis,2001,60(1):35-46.
[5]de Vries JS.Treatment of subtrochanteric nonunions[J].Injury,2006,37(2):203-211.
[6]Sims SH.Subtrochanteric femur fractures[J].Orthop Clin North Am,2002,33(1):113-126.
[7]Parker MJ,Handoll HH.Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults[J].Cochrane Database Syst Rev,2010,(9):Cd000093.
[8]王宗仁,罗先正,刘长贵.GAMMA钉在粗隆间骨折的临床应用[J].中国骨与关节损伤杂志,1996,(1):12-14.
[9]张保中.股骨转子周围骨折的髓内钉固定[J].中华创伤骨科杂志,2002,4(3):192-194.
[10]Hong CC.The long and short of cephalomedullary nails in the treatment of osteoporotic pertrochanteric fracture[J].Singapore Med J,2017,58(2):85-91.
[11]Li Z.Short versus long intramedullary nails for the treatment of intertrochanteric hip fractures in patients older than 65 years[J].Int J Clin Exp Med,2015,8(4):6299-6302.
[12]Raval P.Comparison of short vs long anti-rotation in treating trochanteric fractures[J].Malays Orthop J,2016,10(1):22-28.
[13]Zhang Y.Long and short intramedullary nails for fixation of intertrochanteric femur fractures(OTA 31-A1,A2 and A3):A systematic review and meta-analysis[J].Orthop Traumatol Surg Res,2017,103(5):685-690.
[14]Okcu G.Which implant is better for treating reverse obliquity fractures of the proximal femur:a standard or long nail[J].Clin Orthop Relat Res,2013,471(9):2768-2775.
[15]Boone C.Short versus long intramedullary nails for treatment of intertrochanteric femur fractures(OTA 31-A1 and A2)[J].J Orthop Trauma,2014,28(5):96-100.
[16]Brekelmans WA,Poort HW,Slooff TJ.A new method to analyse the mechanical behaviour of skeletal parts[J].Acta Orthop Scand,1972,43(5):301-317.
[17]Papini M.The biomechanics of human femurs in axial and torsional loading:comparison of finite element analysis,human cadaveric femurs,and synthetic femurs[J].J Biomech Eng,2007,129(1):12-19.
[18]Kuzyk PR.A biomechanical comparison of static versus dynamic lag screw modes for cephalomedullary nails used to fix unstable peritrochanteric fractures[J].J Trauma Acute Care Surg,2012,72(2):65-70.
[19]Seinsheimer F.Subtrochanteric fractures of the femur[J].J Bone Joint Surg Am,1978,60(3):300-306.
[20]Frisch NB.Short versus long cephalomedullary nails for pertrochanteric hip fracture[J].Orthopedics,2017,40(2):83-88.
[21]Marmor M.Biomechanical comparison of long,short,and extended-short nail construct for femoral intertrochanteric fractures[J].Injury,2015,46(6):963-969.
[22]Winiowskj A.Nonunion following intramedullary nailing of the femur with and without reaming.Results of a multicenter randomized clinical trial[J].J Bone Joint Surg Am,2003,85-a(11):2093-2096.
[23]陈贵新,沈学律.PFN结合早期功能锻炼治疗粗隆间骨折及粗隆下骨折[J].中国伤残医学,2011,(5):36-37.
[24]Gardner MP.Mechanical evaluation of large-size fourth-generation composite femur and tibia models[J].Ann Biomed Eng,2010,38(3):613-620.
[25]Eberle S.Auxiliary locking plate improves fracture stability and healing in intertrochanteric fractures fixated by intramedullary nail[J].Clin Biomech(Bristol,Avon),2012,27(10):1006-1010.