PFNA与PCCP固定法治疗不稳定型股骨转子间骨折的有限元分析
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摘要
目的结合股骨转子间骨折六部分分型法,利用有限元分析技术,建立股骨近端防旋髓内钉(proximal femoral nail antirotation,PFNA)、股骨近端经皮加压钢板(percutaneous compression plating,PCCP)分别固定不稳定性股骨转子间骨折的模型,对其进行力学分析,分析两种内固定方式的受力情况。方法建立股骨转子间骨折六部分分型模型,选取其中不稳定性骨折共6种骨折分型均分别以PFNA、PCCP进行固定。将正常股骨及12组股骨内固定结构模型进行有限元分析,得出其Von Mises应力图及Min Principal应力分布,分析内固定模型各重要部位的受力情况。结果不稳定性股骨转子间骨折经PFNA、PCCP固定后,其稳定性均有显著的提升。PFNA固定转子间骨折,降低了股骨近端外侧、内固定物远端内侧及外侧的股骨应力,虽股骨近端内侧应力有所增加,但增加幅度较小,约16%;相较于PCCP而言,PFNA螺钉固定处未见明显的应力集中情况,内固定结构本身应力约为115 MPa,属正常范围。PCCP固定不稳定性转子间骨折时,降低了股骨近端内侧、内固定物远端内侧及外侧的股骨应力,股骨近端外侧应力增加约45%,但尚在正常范围内;PCCP固定后,其螺钉处出现应力集中情况,应力集中约325～326 MPa,内固定物本身结构应力约为412～413 MPa,尚在正常范围内。结论 PFNA是治疗股骨转子间不稳定性股骨转子间骨折的有效手段,能用于治疗股骨转子间骨折六部分分型法中各分型骨折;PCCP由于对股骨近端内侧皮质支撑作用较弱,在用于固定三部分骨折(小转子破裂)及骨折粉碎程度更加严重的骨折时,易发生内固定物失效、髋内翻等并发症,在使用PCCP治疗不稳定性股骨转子间骨折时,应运用适当的方式,将股骨近端内侧壁进行有效固定,恢复其内侧支撑作用。
Objective Combined with the six-part classification method of intertrochanteric fracture, the unstable intertrochanteric fracture was fixed with PFNA and PCCP. A finite element mechanical analysis was carried out to investigate the mechanical stability of PFNA and PCCP in the treatment of unstable intertrochanteric fracture.Methods A six-part classification model of intertrochanteric fracture was established. Six types of unstable fractures were fixed with PFNA, PCCP. The Von Mises stress diagram and Min Principal stress distribution of normal femur and 12 groups of femoral internal fixation structure models were analyzed by finite element method, and the stability of the model was analyzed. Results The stability of unstable intertrochanteric fractures was significantly improved after fixation with PFNA and PCCP. And the stress of the proximal, distal and distal femur was decreased, although the medial stress of the proximal femur was increased. However, the increase was relatively small, about 16%. Compared with PCCP, there was no obvious stress concentration. The stress of internal fixation structure was about 115 MPa,which was in a normal range. PCCP fixed intertrochanteric fracture reduced the stress concentration of the medial proximal femur, distal medial and lateral stress of the internal fixation. Proximal lateral femoral stress increased by approximately 45%, but still in the normal range. Stress concentrations occurred at the screw( 325-326 MPa), and the structure of the internal fixation( 412-413 MPa) were still in the normal range. Conclusions PFNA is an effective method in the treatment of intertrochanteric femoral fractures and can be used in the treatment of each of the six parts of femoral intertrochanteric fractures. Because of its weak support to the medial femoral cortex, PCCP is prone to produce internal fixation failure, hip varus and other complications when used to fix three-part fractures( lesser trochanter rupture) and severe comminuted fractures. In the treatment of unstable intertrochanteric fractures with PCCP, the medial support of the proximal femur should be effectively fixed by appropriate methods.
Objective Combined with the six-part classification method of intertrochanteric fracture, the unstable intertrochanteric fracture was fixed with PFNA and PCCP. A finite element mechanical analysis was carried out to investigate the mechanical stability of PFNA and PCCP in the treatment of unstable intertrochanteric fracture.Methods A six-part classification model of intertrochanteric fracture was established. Six types of unstable fractures were fixed with PFNA, PCCP. The Von Mises stress diagram and Min Principal stress distribution of normal femur and 12 groups of femoral internal fixation structure models were analyzed by finite element method, and the stability of the model was analyzed. Results The stability of unstable intertrochanteric fractures was significantly improved after fixation with PFNA and PCCP. And the stress of the proximal, distal and distal femur was decreased, although the medial stress of the proximal femur was increased. However, the increase was relatively small, about 16%. Compared with PCCP, there was no obvious stress concentration. The stress of internal fixation structure was about 115 MPa,which was in a normal range. PCCP fixed intertrochanteric fracture reduced the stress concentration of the medial proximal femur, distal medial and lateral stress of the internal fixation. Proximal lateral femoral stress increased by approximately 45%, but still in the normal range. Stress concentrations occurred at the screw( 325-326 MPa), and the structure of the internal fixation( 412-413 MPa) were still in the normal range. Conclusions PFNA is an effective method in the treatment of intertrochanteric femoral fractures and can be used in the treatment of each of the six parts of femoral intertrochanteric fractures. Because of its weak support to the medial femoral cortex, PCCP is prone to produce internal fixation failure, hip varus and other complications when used to fix three-part fractures( lesser trochanter rupture) and severe comminuted fractures. In the treatment of unstable intertrochanteric fractures with PCCP, the medial support of the proximal femur should be effectively fixed by appropriate methods.
引文
[1]Kouzelis A,Kravvas A,Mylonas S,et al.Double axis cephalocondylic fixation of stable and unstable intertrochanteric fractures:early results in 60 cases with the veronail system[J].Open Orthop J,2014,8:60-68.
[2]Castillón P,Bartra A,Vallejo G,et al.Hip arthroplasty with conventional stem as rescue treatment after failed treatment of intertrochanteric hip fractures[J].Rev Esp Cir Ortop Traumatol,2013,57(3):194-200.
[3]Wada K,Mikami H,Oba K,et al.Cementless calcarreplacement stem with integrated greater trochanter plate for unstable intertrochanteric fracture in very elderly patients[J].J Orthop Surg(Hong Kong),2017,25(1):1-8.
[4]Chehade MJ,Carbone T,Awward D,et al.Influence of fracture stability on early patient mortality and reoperation after pertrochanteric and intertrochanteric hip fractures[J].J Orthop Trauma,2015,29(12):538-543.
[5]姬晨妮,陈伟,朱燕宾,等.京津唐地区1583例老年股骨转子间骨折流行病学特征分析[J].中华老年骨科与康复电子杂志,2015,(1):45-49.
[6]Hartholt KA,van Beeck EF,Polinder S,et al.Societal consequences of falls in the older population:injuries,healthcare costs,and long-term reduced quality of life[J].J Trauma,2011,71(3):748-753.
[7]Isida R,Bariatinsky V,Kern G,et al.Prospective study of the reproducibility of X-rays and CT scans For assessing trochanteric fracture comminution in the elderly:a series of 110cases[J].Eur J Orthop Surg Traumatol,2015,(7):1165-1170.
[8]Cavaignac E,Lecoq M,Ponsot A,et al.CT scan does not improve the reproducibility of trochanteric fracture classification:a prospective observational study of 53 cases[J].Orthop Traumatol Surg Res,2013,99(1):46-51.
[9]余清文,张里程,毛志,等.CT三维重建与X射线片应用于转子间骨折分型的可靠性[J].中国组织工程研究,2012,16(22):4075-4079.
[10]郭小微.股骨转子部骨折六部分骨折分型及创伤评分系统(KNXW)的研究[D].遵义医学院,2014.
[11]陈振沅,李开南,张之玺,等.股骨转子间六部分骨折分型产生机制的有限元分析[J].中华创伤骨科杂志,2015,17(5):433-437.
[12]郑颖捷.基于计算机技术对股骨转子间骨折六部分分型的相关研究[D].遵义医学院,2017.
[13]Maheshwari K,Planchard J,You J,et al.Early surgery confers1-year mortality benefit in hip-fracture patients[J].J Orthop Trauma,2018,32(3):105-110.
[14]Li K,Zheng Y.Internal fixation versus conservative treatment for elderly patients with a trochanteric hip fracture in conjunction with post-stroke hemiplegia[J].Injury,2016,47:2169-2172.
[15]Frenkel Rutenberg T,Daglan E,Heller S,et al.A comparison of treatment setting for elderly patients with hip fracture,is the geriatric ward superior to conventional orthopedic hospitalization[J]?Injury,2017,48:1584-1588.
[16]Yoo JI,Ha YC,Lim JY,et al.Early rehabilitation in elderly after arthroplasty versus internal fixation for unstable intertrochanteric fractures of femur:systematic review and meta-analysis[J].J Korean Med Sci,2017,32:858-867.
[17]van de Ree CLP,De Jongh MAC,Peeters CMM,et al.Hip fractures in elderly people:surgery or no surgery?A systematic review and meta-analysis[J].Geriatr Orthop Surg Rehabil,2017,8(3):173-180.
[18]Fu MC,Boddapati V,Gausden EB,et al.Surgery for a fracture of the hip within 24 hours of admission is independently associated with reduced short-term post-operative complications[J].Bone Joint J,2017,99-B(9):1216-1222.
[19]Díaz VJ,Ca?izares AC,Martín IA,et al.Predictive variables of open reduction in intertrochanteric fracture nailing:a report of210 cases[J].Injury,2016,47(Suppl 3):S51-55.
[20]Sitthiseripratip K,Van Oosterwyck H,Vander Sloten J,et al.Finite element study of trochanteric gamma nail for trochanteric fracture[J].Med Eng Phys,2003,25(2):99-106.
[21]Kobayashi E,Wang TJ,Doi H,et al.Mechanical properties and corrosion resistance of Ti-6Al-7Nb alloy dental castings[J].J Mat Sci Mater Med,1998,9(10):567-574.
[22]Wirtz DC,Pandorf T,Portheine F,et al.Concept and development of an orthotropic FE model of the proximal femur[J].J Biomechanics,2003,36(2):289-293.
[23]叶书熙.股骨近端新型解剖锁定钢板的应用解剖学及生物力学三维有限元研究[D].南方医科大学,2013:3.
[24]林松青,王彬,张磊,等.有限元分析在骨科中的应用及研究进展[J].中国中医骨伤科杂志,2013(4).
[25]赵京涛,樊粤光,袁浩,等.有限元方法在临床骨科生物力学研究中的应用[J].中医正骨,2002,14(4):51-53.
[26]Nayak S,Edwards DL,Saleh AA,et al.Performance of risk assessment instruments for predicting osteoporotic fracture risk:a systematic review[J].Osteoporosis International,2014,25(1):23-49.
[27]Gómez-Benito MJ,García-Aznar JM,DoblaréM.Finite element prediction of proximal femoral fracture patterns under different loads[J].J Biomechanical Engineering,2005,127(1):9.
[28]Widjaja W,Hartung C.Finite element analysis of an additional implant for intramedullary nailing[J].Biomedizinische Technik,2000,45(12):338-342.
[29]Wu X,Ming Y,Wu L,et al.A biomechanical comparison of two intramedullary implants for subtrochanteric fracture in two healing stages:a finite element analysis[J].Appl Bionics Biomech,2015,2015:1-7.
[30]Chen Y,Wang G,Zhou D,et al.Computational study in effects of nail-and plate-implants on the treatment of pertrochanteric and intertrochanteric fractures[J].Mater Perform Charact,2015,4(1):MPC20140057.
[31]Hou W,Zhang W,Zhao H.Analysis on three-dimensional finite element of rebuilding femoral calcar in femoral head replacement[J].J Modern Med Health,2015,21(6):1585-1592.
[32]Polikeit A,Nolte LP,Ferguson SJ.The effect of cement augmentation on the load transfer in an osteoporotic functional spinal unit:finite-element analysis[J].Spine,2003,28(10):991-996.
[33]Zhu XH,Gong H,Bai XF.The elastic modular and surface density in segmental function of distal femeral stimulate structure[J].Zhongguo Shengwu Yixue Gongcheng Xuebao,2003,22(3):250-257.
[34]陈少明,邱玉金,卢斌,等.不稳定股骨转子间骨折不同内固定方式的三维有限元分析[J].中国组织工程研究,2016,20(26):3890-3896.
[35]Hélin M,Pelissier A,Boyer P,et al.Does the PFNATM nail limit impaction in unstable intertrochanteric femoral fracture?A 115 case-control series[J].Orthop Traumatol Surg Res,2015,101(1):45-49.
[36]Verettas DA,Ifantidis P,Chatzipapas CN,et al.Systematic effects of surgical treatment of hip fractures:gliding screwplating vs intramedullary nailing[J].Injury,2010,41(3):279-284.
[37]Yu W,Zhang X,Wu R,et al.The visible and hidden blood loss of Asia proximal femoral nail anti-rotation and dynamic hip screw in the treatment of intertrochanteric fractures of elderly high-risk patients:a retrospective comparative study with a minimum 3 years of follow-up[J].BMC Musculoskelet Disord,2016,17:269.
[38]Knobe M,Münker R,Schmidt-Rohlfing B,et al.Surgical outcome in pertroch-anteric femur fracture:the impact of osteoporosis.Comparison between DHS and percutaneous compression plate[J].Zeitschrift Fur Orthopadie Und Unfallchirurgie,2016,146(1):44.
[39]张斌,常军,杨志刚,等.内侧壁缺损面积对股骨转子间骨折经皮加压钢板固定术后断端稳定性影响的实验研究[J].中华创伤骨科杂志,2016,18(1):61-65.
[40]Evans EM.The treatment of trochanteric fractures of the femur[J].J Bon E Joint Surg Br,1949,31(2):190-203.
[41]Jensen JS,Michaelsen M.Trochanteric femoral fractures treated with McLaughlin osteosynthesis[J].Acta Orthop Scand,1975,46(5):795-803.
[42]Kinast C,Bolhofner BR,Mast JW,et al.Subtrochanteric fractures of the femur.Results of treatment with the 95 degrees condylar blade-plate[J].Clin Orthop Relat Res,1989,238:122-130.
[43]张君哲,朱康.六部分骨折分型在减少和预防股骨转子部骨折患者围手术期风险中的应用[J].临床和实验医学杂志,2017,16(13):1319-1322.
[44]郑颖捷,李开南.股骨转子间骨折外侧壁的研究进展[J].中华创伤骨科杂志,2017,19(2):133-137.
[2]Castillón P,Bartra A,Vallejo G,et al.Hip arthroplasty with conventional stem as rescue treatment after failed treatment of intertrochanteric hip fractures[J].Rev Esp Cir Ortop Traumatol,2013,57(3):194-200.
[3]Wada K,Mikami H,Oba K,et al.Cementless calcarreplacement stem with integrated greater trochanter plate for unstable intertrochanteric fracture in very elderly patients[J].J Orthop Surg(Hong Kong),2017,25(1):1-8.
[4]Chehade MJ,Carbone T,Awward D,et al.Influence of fracture stability on early patient mortality and reoperation after pertrochanteric and intertrochanteric hip fractures[J].J Orthop Trauma,2015,29(12):538-543.
[5]姬晨妮,陈伟,朱燕宾,等.京津唐地区1583例老年股骨转子间骨折流行病学特征分析[J].中华老年骨科与康复电子杂志,2015,(1):45-49.
[6]Hartholt KA,van Beeck EF,Polinder S,et al.Societal consequences of falls in the older population:injuries,healthcare costs,and long-term reduced quality of life[J].J Trauma,2011,71(3):748-753.
[7]Isida R,Bariatinsky V,Kern G,et al.Prospective study of the reproducibility of X-rays and CT scans For assessing trochanteric fracture comminution in the elderly:a series of 110cases[J].Eur J Orthop Surg Traumatol,2015,(7):1165-1170.
[8]Cavaignac E,Lecoq M,Ponsot A,et al.CT scan does not improve the reproducibility of trochanteric fracture classification:a prospective observational study of 53 cases[J].Orthop Traumatol Surg Res,2013,99(1):46-51.
[9]余清文,张里程,毛志,等.CT三维重建与X射线片应用于转子间骨折分型的可靠性[J].中国组织工程研究,2012,16(22):4075-4079.
[10]郭小微.股骨转子部骨折六部分骨折分型及创伤评分系统(KNXW)的研究[D].遵义医学院,2014.
[11]陈振沅,李开南,张之玺,等.股骨转子间六部分骨折分型产生机制的有限元分析[J].中华创伤骨科杂志,2015,17(5):433-437.
[12]郑颖捷.基于计算机技术对股骨转子间骨折六部分分型的相关研究[D].遵义医学院,2017.
[13]Maheshwari K,Planchard J,You J,et al.Early surgery confers1-year mortality benefit in hip-fracture patients[J].J Orthop Trauma,2018,32(3):105-110.
[14]Li K,Zheng Y.Internal fixation versus conservative treatment for elderly patients with a trochanteric hip fracture in conjunction with post-stroke hemiplegia[J].Injury,2016,47:2169-2172.
[15]Frenkel Rutenberg T,Daglan E,Heller S,et al.A comparison of treatment setting for elderly patients with hip fracture,is the geriatric ward superior to conventional orthopedic hospitalization[J]?Injury,2017,48:1584-1588.
[16]Yoo JI,Ha YC,Lim JY,et al.Early rehabilitation in elderly after arthroplasty versus internal fixation for unstable intertrochanteric fractures of femur:systematic review and meta-analysis[J].J Korean Med Sci,2017,32:858-867.
[17]van de Ree CLP,De Jongh MAC,Peeters CMM,et al.Hip fractures in elderly people:surgery or no surgery?A systematic review and meta-analysis[J].Geriatr Orthop Surg Rehabil,2017,8(3):173-180.
[18]Fu MC,Boddapati V,Gausden EB,et al.Surgery for a fracture of the hip within 24 hours of admission is independently associated with reduced short-term post-operative complications[J].Bone Joint J,2017,99-B(9):1216-1222.
[19]Díaz VJ,Ca?izares AC,Martín IA,et al.Predictive variables of open reduction in intertrochanteric fracture nailing:a report of210 cases[J].Injury,2016,47(Suppl 3):S51-55.
[20]Sitthiseripratip K,Van Oosterwyck H,Vander Sloten J,et al.Finite element study of trochanteric gamma nail for trochanteric fracture[J].Med Eng Phys,2003,25(2):99-106.
[21]Kobayashi E,Wang TJ,Doi H,et al.Mechanical properties and corrosion resistance of Ti-6Al-7Nb alloy dental castings[J].J Mat Sci Mater Med,1998,9(10):567-574.
[22]Wirtz DC,Pandorf T,Portheine F,et al.Concept and development of an orthotropic FE model of the proximal femur[J].J Biomechanics,2003,36(2):289-293.
[23]叶书熙.股骨近端新型解剖锁定钢板的应用解剖学及生物力学三维有限元研究[D].南方医科大学,2013:3.
[24]林松青,王彬,张磊,等.有限元分析在骨科中的应用及研究进展[J].中国中医骨伤科杂志,2013(4).
[25]赵京涛,樊粤光,袁浩,等.有限元方法在临床骨科生物力学研究中的应用[J].中医正骨,2002,14(4):51-53.
[26]Nayak S,Edwards DL,Saleh AA,et al.Performance of risk assessment instruments for predicting osteoporotic fracture risk:a systematic review[J].Osteoporosis International,2014,25(1):23-49.
[27]Gómez-Benito MJ,García-Aznar JM,DoblaréM.Finite element prediction of proximal femoral fracture patterns under different loads[J].J Biomechanical Engineering,2005,127(1):9.
[28]Widjaja W,Hartung C.Finite element analysis of an additional implant for intramedullary nailing[J].Biomedizinische Technik,2000,45(12):338-342.
[29]Wu X,Ming Y,Wu L,et al.A biomechanical comparison of two intramedullary implants for subtrochanteric fracture in two healing stages:a finite element analysis[J].Appl Bionics Biomech,2015,2015:1-7.
[30]Chen Y,Wang G,Zhou D,et al.Computational study in effects of nail-and plate-implants on the treatment of pertrochanteric and intertrochanteric fractures[J].Mater Perform Charact,2015,4(1):MPC20140057.
[31]Hou W,Zhang W,Zhao H.Analysis on three-dimensional finite element of rebuilding femoral calcar in femoral head replacement[J].J Modern Med Health,2015,21(6):1585-1592.
[32]Polikeit A,Nolte LP,Ferguson SJ.The effect of cement augmentation on the load transfer in an osteoporotic functional spinal unit:finite-element analysis[J].Spine,2003,28(10):991-996.
[33]Zhu XH,Gong H,Bai XF.The elastic modular and surface density in segmental function of distal femeral stimulate structure[J].Zhongguo Shengwu Yixue Gongcheng Xuebao,2003,22(3):250-257.
[34]陈少明,邱玉金,卢斌,等.不稳定股骨转子间骨折不同内固定方式的三维有限元分析[J].中国组织工程研究,2016,20(26):3890-3896.
[35]Hélin M,Pelissier A,Boyer P,et al.Does the PFNATM nail limit impaction in unstable intertrochanteric femoral fracture?A 115 case-control series[J].Orthop Traumatol Surg Res,2015,101(1):45-49.
[36]Verettas DA,Ifantidis P,Chatzipapas CN,et al.Systematic effects of surgical treatment of hip fractures:gliding screwplating vs intramedullary nailing[J].Injury,2010,41(3):279-284.
[37]Yu W,Zhang X,Wu R,et al.The visible and hidden blood loss of Asia proximal femoral nail anti-rotation and dynamic hip screw in the treatment of intertrochanteric fractures of elderly high-risk patients:a retrospective comparative study with a minimum 3 years of follow-up[J].BMC Musculoskelet Disord,2016,17:269.
[38]Knobe M,Münker R,Schmidt-Rohlfing B,et al.Surgical outcome in pertroch-anteric femur fracture:the impact of osteoporosis.Comparison between DHS and percutaneous compression plate[J].Zeitschrift Fur Orthopadie Und Unfallchirurgie,2016,146(1):44.
[39]张斌,常军,杨志刚,等.内侧壁缺损面积对股骨转子间骨折经皮加压钢板固定术后断端稳定性影响的实验研究[J].中华创伤骨科杂志,2016,18(1):61-65.
[40]Evans EM.The treatment of trochanteric fractures of the femur[J].J Bon E Joint Surg Br,1949,31(2):190-203.
[41]Jensen JS,Michaelsen M.Trochanteric femoral fractures treated with McLaughlin osteosynthesis[J].Acta Orthop Scand,1975,46(5):795-803.
[42]Kinast C,Bolhofner BR,Mast JW,et al.Subtrochanteric fractures of the femur.Results of treatment with the 95 degrees condylar blade-plate[J].Clin Orthop Relat Res,1989,238:122-130.
[43]张君哲,朱康.六部分骨折分型在减少和预防股骨转子部骨折患者围手术期风险中的应用[J].临床和实验医学杂志,2017,16(13):1319-1322.
[44]郑颖捷,李开南.股骨转子间骨折外侧壁的研究进展[J].中华创伤骨科杂志,2017,19(2):133-137.