股骨交锁髓内钉锁钉的生物力学研究
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摘要
目的：近年来，交锁髓内钉已广泛应用于临床，特别是对长骨干骨折治疗疗效显著，但术后也存在一些并发症，断钉是严重并发症之一。本课题通过测定股骨交锁髓内钉锁钉的生物力学变化，旨在为临床分析锁钉断裂的原因，哪枚锁钉易发生疲劳断裂以及远端应该用几枚锁钉固定提供依据。
方法：六具青壮年防腐股骨标本，剔除软组织后远端用牙托粉包埋固定，测量长度并X线摄片以排除骨病，同时测量髓腔直径(髓腔最狭窄处)。标本用夹具固定后装于MTS试验机，锁钉处安装MTS位移传感器，轴向加载0-500N，加载速度为50N／sec，MTS自动加载，MTS位移传感器自动记录位移，计算机自动处理数据。每具标本分六个状态，按a-f组测量顺序进行重复测量：a，正常股骨；b，安装交锁髓内钉模拟骨折愈合；c，股骨中段横形或小斜形锯断模拟稳定型骨折；d，在c组的基础上远端去除一枚锁钉；e，在c组基础上股骨中段制成1.5cm骨缺损模拟不稳定型骨折；f，在e组基础上远端去除一枚锁钉。分别测量各锁钉处应变变化，并进行统计学分析(重复测量的方差分析)。
结果：各种状态下近端锁钉间应变均无显著性差异(p＞0.05)；近端锁钉与远端锁钉之间应变存在显著性差异(p＜0.05)；远端锁钉间应变除正常股骨及稳定型骨折外均存在显著性差异(p＜0.05)；远端去除一枚锁钉固定时剩余远端钉表现比原来大的应变。第一枚锁钉和第二枚锁钉的应变在稳定骨折及其远端去除一枚锁钉、不稳定骨折及其远端去除一枚锁钉的状态比较时无显著性差异(p＞0.05)，在其他状态之间均有显著性差异(p＜0.05)。第三枚锁钉在所有状态之间均有显著性差异(p＜0.05)。第四枚锁钉在正常股骨与骨折愈合后无显著性差异；其他状态之间均有显著性差异。
结论：骨折线远端的锁钉易发生断裂，尤其是靠近骨折线者；尽量
以两枚锁钉固定远端并远离骨折线。骨折愈合后应及时取出内固定物，
或者在有丰富的骨俪形成后去除锁钉，变静力型固定为动力型固定。
Objective:The interlocking fixation has been widely used in clinics,especially in treating the limbs fractures. Though as an effective method,it also has many postoperative complications. Nail breakage is the most serious one. The study aims at analyzing the causes of interlocking nails breakage,which one tend towards failure fragmentation and how many nails should be put in distal fracture segment.
Methods:Six antiseptic adult femora were used,clearing all soft tissue and coating the distal tip with dental base acrylic resin powder. All femoral were length measured and X-ray photographed to evacuate osteopathies and measure the diameters of medullary cavities. Specimen were fixed and installed on MTS machine,put on migration sensor on each inter-locking nail,axial compression was 0-500N,average 50N/sec,auto compressed by MTS machine,migration (or strain ) auto receded from sensors and data processed in computer. Each specimen tested under six conditions at (a)-(f) sequence:(a),normal;(b),install the interlocking intramedullary nail to simulate cured fracture;(c),saw an across or slope crack to simulate the stable fracture;(d),as(c) and remove a distal interlocking nail;(e),as (c)and saw asunder a 1.5cm fragment to simulate unstable fracture;(f),as(e)and remove one distal nail. Measured the stress and strain changes on every interlocking nail and did the statistical analysis.
Results:All six conditions showed no notable stress and strain changes at proximal interlocking nails (p>0.05);which were significant between distal and proximal (p<0.05);stress and strain had the outstanding changes in distal ones except the normal and stable fracture groups (p<0.05);those groups removed one distal interlocking nail,another one should endure much stress
and had more strain. The stress and strain changes on the first and second interlocking nail were not significant at those unstable fractures and with one of their distal nails removed,but significant at other conditions. The third nail happened marked changes at every conditions. The forth one had the significant changes except the normal and cured fractures. Conclusions:Interlocking nails under the crack tend towards broken especially very near it,as far as possible apply two nails interlocking the distal fracture and apart from the crack. Internal fixation instruments should be removed at time when the fractures had cured or removed the interlocking nails when had the sufficient bony callus,which turn the quiescenced fixation into mobilized fixation.
方法：六具青壮年防腐股骨标本，剔除软组织后远端用牙托粉包埋固定，测量长度并X线摄片以排除骨病，同时测量髓腔直径(髓腔最狭窄处)。标本用夹具固定后装于MTS试验机，锁钉处安装MTS位移传感器，轴向加载0-500N，加载速度为50N／sec，MTS自动加载，MTS位移传感器自动记录位移，计算机自动处理数据。每具标本分六个状态，按a-f组测量顺序进行重复测量：a，正常股骨；b，安装交锁髓内钉模拟骨折愈合；c，股骨中段横形或小斜形锯断模拟稳定型骨折；d，在c组的基础上远端去除一枚锁钉；e，在c组基础上股骨中段制成1.5cm骨缺损模拟不稳定型骨折；f，在e组基础上远端去除一枚锁钉。分别测量各锁钉处应变变化，并进行统计学分析(重复测量的方差分析)。
结果：各种状态下近端锁钉间应变均无显著性差异(p＞0.05)；近端锁钉与远端锁钉之间应变存在显著性差异(p＜0.05)；远端锁钉间应变除正常股骨及稳定型骨折外均存在显著性差异(p＜0.05)；远端去除一枚锁钉固定时剩余远端钉表现比原来大的应变。第一枚锁钉和第二枚锁钉的应变在稳定骨折及其远端去除一枚锁钉、不稳定骨折及其远端去除一枚锁钉的状态比较时无显著性差异(p＞0.05)，在其他状态之间均有显著性差异(p＜0.05)。第三枚锁钉在所有状态之间均有显著性差异(p＜0.05)。第四枚锁钉在正常股骨与骨折愈合后无显著性差异；其他状态之间均有显著性差异。
结论：骨折线远端的锁钉易发生断裂，尤其是靠近骨折线者；尽量
以两枚锁钉固定远端并远离骨折线。骨折愈合后应及时取出内固定物，
或者在有丰富的骨俪形成后去除锁钉，变静力型固定为动力型固定。
Objective:The interlocking fixation has been widely used in clinics,especially in treating the limbs fractures. Though as an effective method,it also has many postoperative complications. Nail breakage is the most serious one. The study aims at analyzing the causes of interlocking nails breakage,which one tend towards failure fragmentation and how many nails should be put in distal fracture segment.
Methods:Six antiseptic adult femora were used,clearing all soft tissue and coating the distal tip with dental base acrylic resin powder. All femoral were length measured and X-ray photographed to evacuate osteopathies and measure the diameters of medullary cavities. Specimen were fixed and installed on MTS machine,put on migration sensor on each inter-locking nail,axial compression was 0-500N,average 50N/sec,auto compressed by MTS machine,migration (or strain ) auto receded from sensors and data processed in computer. Each specimen tested under six conditions at (a)-(f) sequence:(a),normal;(b),install the interlocking intramedullary nail to simulate cured fracture;(c),saw an across or slope crack to simulate the stable fracture;(d),as(c) and remove a distal interlocking nail;(e),as (c)and saw asunder a 1.5cm fragment to simulate unstable fracture;(f),as(e)and remove one distal nail. Measured the stress and strain changes on every interlocking nail and did the statistical analysis.
Results:All six conditions showed no notable stress and strain changes at proximal interlocking nails (p>0.05);which were significant between distal and proximal (p<0.05);stress and strain had the outstanding changes in distal ones except the normal and stable fracture groups (p<0.05);those groups removed one distal interlocking nail,another one should endure much stress
and had more strain. The stress and strain changes on the first and second interlocking nail were not significant at those unstable fractures and with one of their distal nails removed,but significant at other conditions. The third nail happened marked changes at every conditions. The forth one had the significant changes except the normal and cured fractures. Conclusions:Interlocking nails under the crack tend towards broken especially very near it,as far as possible apply two nails interlocking the distal fracture and apart from the crack. Internal fixation instruments should be removed at time when the fractures had cured or removed the interlocking nails when had the sufficient bony callus,which turn the quiescenced fixation into mobilized fixation.
引文
1．陆裕朴，葛宝丰，卢世璧，等．实用骨科学．第一版，北京：人民军医出版社，1991：660
2．吴阶平，裘法祖，等．黄家驷外科学．第五版，北京：人民卫生出版社，1992：2177
3. Rrpeen SM. The concept of biological plating using the limited contact-dynamic compression plate (LC-DCP).Scientific background, design and application.Injury,1991; 22:1-41
4. Karnezis IA, Miles AW,Cunningham JL,et al."Biological" internal fixation of long bone fractures: a biomechanical study of a "noncontact" plate system. Injury, 1998,29(9): 689-695
5. Chrisovitsinos JP, Xenakis T, Papakostides GK,et al. Bridge plating osteosynthesis of 20 comminuted fractures of the femur.Acta Orthop Scand Suppl,1997,275:72-76
6. Sun J, Abel EW, Rowley DI. Mechanical performance of an axially mobile plate for fracture fixation.J Trauma, 1998,44(2):368-371
7．杨立民，张继明，沈金根．角形接骨板的研制与应用．中华骨科杂志，1992,1：69-71
8．赵建宁，汤发强，王与荣，等．波形钢板治疗股骨干骨折．骨与关节损伤杂志，1999,14(2)：114-115
9. Chiu FY,Lo WH, Chen CM, et al.Unstable closed tibial shaft fractures:a prospective evaluation of surgical treatment.J Trauma,1996, 40 (6):987 -997
10. Gynning JB, Hansen D.Treatment of distal femoral fractures with intramedullary supracndylar nails in elderly patients.Injury,1999, 30(1): 43 -46
11. Leung KS, Shen WY, So WS, et al. Interlocking intramedullary nailing for supracondylar and intercondylar fractures of the distal parts of the femur.J Bone Joint Surg Am,1991,73(3):332-340
12. Scheerlink T, Krallis P, Descamps PY, et al. The femoral supracondylar nail:preliminary experience.Acta Orthop Belg, 1998,64(4):385-392
13. Stromsoe K, Alho A. The Groose-kempf nail for distal femoral fractures.Acta Orthop Scand,1990,61:512-514
14. Ebraheim NA, Paley KJ. Penetration of the distal femur by the distal locking device of Brooker-Wills interlocking nail.Clin Orthop,1993,297:218-223
15. Danziger MB, Caucci D, Zecher SB, et al. Treatment of intercondylar and supracondylar distal femur fractures using the GSH supracondylar nail. Am J Orthop, 1995,24(9):684-690
16．罗先正，邱贵兴．髓内钉内固定．北京：人民卫生出版社，199770-72
17．李文任，刘建华，邹伟民，等．带锁髓内钉治疗成人股骨干骨折38例临床体会．广州医药,2001,32(1)：39-40
18．叶林根，杨少岩．交锁钉内固定治疗下肢长骨干骨折．中国骨伤，2000,13(12)：738-739
19．李连亭，刘一星．应用带锁钉治疗股骨骨折74例报告．中国矫形外科杂志，2001，8(3)：290-291
20．孙旭海，范锡海，闫勇，等．髓内固定治疗四肢管状骨骨折600例。中华创伤杂志，2001，17(6)：371-372
21．万仑，张耀明，吕波，等．交锁髓内钉治疗粉碎性下肢长骨干骨折不愈合23例．中华创伤杂志,2001，17(3)：145-147
22．Joseph Schatzker，姜春岩．AO／ASIF原则与方法的变迁．创伤骨科学报，1996,25(3)：205-207
23．黄彦，王胜标．股骨干骨折交锁髓内钉固定所致并发症的原因分析及处理．中华创伤杂志，2001，17(5)：290-292
24．徐卫东，吴岳嵩，张春才，等。交锁髓内钉断裂的原因分析及对策．中国矫形外科杂志，1999，6(3)：194-196
25. Whittle AP, Wester W, Rusell TA. Fatigue in small diameter tibial nail.Clin Orthop,1995,(315): 119-128
26. Haddad FS, Desai K, Sarkar JS, et al. The AO undreamed nail: friend or foe.Injury, 1996,7(4):261-263
27. Sargeant ID, Lovell M, Casserley H, et al. The AO undreamed tibial nail:a 14-month follow-up of the 1992 TT experience. Injury,1994, 25(7): 423-425
28. Giannoudis PY, urlong AJ, Macdonald DA, et al.Reamed against unreamed nailing of the femoral diaphysis:a retrospective study of healing time. Injury, 1997,28(1): 15-18
29．刘长贵，张宝中，郭艾，等．带锁髓内钉治疗股骨干骨折并发症及防治，中华骨科杂志，1998,8(12)：725-727
30．徐卫东，张春才，吴岳嵩，等．股骨交锁髓内钉应用的并发症和防治．解放军医学杂志，2000,25(4)：252-254
31. Schemitsch EH, Turchin DC, Kowalski MJ, et al. Quantitative assessment of bone injury and repair after reamed and unreamed locked intramedullary nailing.J Trauma. 1998;45(2):250-255
32. Strecker W.Local complications of intramedullary nailing. Orthopade,1996, 25:270-273
33．杨雍，刘长贵，罗先正．带锁髓内钉治疗股骨干骨折不愈合、延迟愈合．骨与关节损伤杂志，1998,13：269-271
34．印心奇，徐根宝，顾小华，等．交锁髓内钉的临床应用体会．中国矫形外科杂志，1998，5：410-411
35．朱建民．骨折愈合的一些新概念．中华创伤杂志，1996，12：268-270
36. Statis P, Rokkanen P. Closed intramedullary nailing of tibial shaft fracture:a comparison with conservatively treated cases. Acta Orthop Scand, 1967,38:88-90
37. Kessler SB,Hallfeldt KKT, Perren SM,et al.the effects of reaming and intramedullary nailing on fracture healing,Clin Orthop,1986,212:18-20
38. Cole J,Ansel LJ,Schwartzberg R.A sequential protocol for management of severe open tibial fractures.Clin Orthop,1995,315:84-86
39. A Darder Garcia,A Darder Pats,F gomar sancho.Nonreamed flexible locked intramadullary nailing in tibial open fractures.Clin Orthop,1998,350:97-104
40. Manfred Greitbauer, Thomas Heinz,Christian Gaebler,et al Unreamed nailing of tibial fractures with the solid tibial nail.Clin Orthop, 1998,350:105-114
41. Henley MB, Chapman JR, Agel J, et al. Treatment of type Ⅱ, ⅢA and ⅢB open fractures of the tibial shaft:a prospective comparison of unreamed interlocking in tramedullary nails and half-pin external fixators. J Orthop Trauma,1998,12(1):1-7
42. Wolinsky PR,Mccarty E,Shyr Y,et al.Reamed intramedullary nailing of the femur:551 cases.J Trauma,1999,46(3):392-398
43. Bucholz RW,Ross SE, Lawrence KL. Fatigue fracture of the interlocking nail in the treatment of fracture of the distalpar of the femoral shaft. J Bone Joint Surg, 1987, 69:1391-1397
44. Wu CC,Shih CH.Biomechanical analysis of the mechanism of interlocking nail failure.Arch Orthop Trauma Surge, 1992,111:268-269
45. Bankston AB, Keating EM, Saha S. The biomechanical valuation of intramedullary nails in distal femoral shaft fractures.Clin Orthop, 1992,276:277-278
46．吴乃庆，宋李军，王道新，等。鱼口交锁髓内钉和其它三种交锁髓内钉的生物力学性能比较．中华骨科杂志，1997，17(4)：233-234
47. Whittle AP, Wester W, Rusell TA. Fatigue failure in small diameter tibital nail. Clin Orthop.1995,3(15): 119-128
48. Haddad FS, Sarkar JS. The AO unreamed nail: friend or foe.Injury,1996,7(4): 261-263
49. Sargeant ID, Lovell M, Casserley H, et al. The AO unreamed tibial nail:a 14-month follow-up of the 1992 TT experience. Injury, 1994, 25(7):423-425
50. Giannoudis PV, Furlong A J, Macdonald DA, et al.Reamed against unreamed nailing of the femoral diaphysis:a retrospective study of healing time.Injury, 1997,28(1): 15-18
2．吴阶平，裘法祖，等．黄家驷外科学．第五版，北京：人民卫生出版社，1992：2177
3. Rrpeen SM. The concept of biological plating using the limited contact-dynamic compression plate (LC-DCP).Scientific background, design and application.Injury,1991; 22:1-41
4. Karnezis IA, Miles AW,Cunningham JL,et al."Biological" internal fixation of long bone fractures: a biomechanical study of a "noncontact" plate system. Injury, 1998,29(9): 689-695
5. Chrisovitsinos JP, Xenakis T, Papakostides GK,et al. Bridge plating osteosynthesis of 20 comminuted fractures of the femur.Acta Orthop Scand Suppl,1997,275:72-76
6. Sun J, Abel EW, Rowley DI. Mechanical performance of an axially mobile plate for fracture fixation.J Trauma, 1998,44(2):368-371
7．杨立民，张继明，沈金根．角形接骨板的研制与应用．中华骨科杂志，1992,1：69-71
8．赵建宁，汤发强，王与荣，等．波形钢板治疗股骨干骨折．骨与关节损伤杂志，1999,14(2)：114-115
9. Chiu FY,Lo WH, Chen CM, et al.Unstable closed tibial shaft fractures:a prospective evaluation of surgical treatment.J Trauma,1996, 40 (6):987 -997
10. Gynning JB, Hansen D.Treatment of distal femoral fractures with intramedullary supracndylar nails in elderly patients.Injury,1999, 30(1): 43 -46
11. Leung KS, Shen WY, So WS, et al. Interlocking intramedullary nailing for supracondylar and intercondylar fractures of the distal parts of the femur.J Bone Joint Surg Am,1991,73(3):332-340
12. Scheerlink T, Krallis P, Descamps PY, et al. The femoral supracondylar nail:preliminary experience.Acta Orthop Belg, 1998,64(4):385-392
13. Stromsoe K, Alho A. The Groose-kempf nail for distal femoral fractures.Acta Orthop Scand,1990,61:512-514
14. Ebraheim NA, Paley KJ. Penetration of the distal femur by the distal locking device of Brooker-Wills interlocking nail.Clin Orthop,1993,297:218-223
15. Danziger MB, Caucci D, Zecher SB, et al. Treatment of intercondylar and supracondylar distal femur fractures using the GSH supracondylar nail. Am J Orthop, 1995,24(9):684-690
16．罗先正，邱贵兴．髓内钉内固定．北京：人民卫生出版社，199770-72
17．李文任，刘建华，邹伟民，等．带锁髓内钉治疗成人股骨干骨折38例临床体会．广州医药,2001,32(1)：39-40
18．叶林根，杨少岩．交锁钉内固定治疗下肢长骨干骨折．中国骨伤，2000,13(12)：738-739
19．李连亭，刘一星．应用带锁钉治疗股骨骨折74例报告．中国矫形外科杂志，2001，8(3)：290-291
20．孙旭海，范锡海，闫勇，等．髓内固定治疗四肢管状骨骨折600例。中华创伤杂志，2001，17(6)：371-372
21．万仑，张耀明，吕波，等．交锁髓内钉治疗粉碎性下肢长骨干骨折不愈合23例．中华创伤杂志,2001，17(3)：145-147
22．Joseph Schatzker，姜春岩．AO／ASIF原则与方法的变迁．创伤骨科学报，1996,25(3)：205-207
23．黄彦，王胜标．股骨干骨折交锁髓内钉固定所致并发症的原因分析及处理．中华创伤杂志，2001，17(5)：290-292
24．徐卫东，吴岳嵩，张春才，等。交锁髓内钉断裂的原因分析及对策．中国矫形外科杂志，1999，6(3)：194-196
25. Whittle AP, Wester W, Rusell TA. Fatigue in small diameter tibial nail.Clin Orthop,1995,(315): 119-128
26. Haddad FS, Desai K, Sarkar JS, et al. The AO undreamed nail: friend or foe.Injury, 1996,7(4):261-263
27. Sargeant ID, Lovell M, Casserley H, et al. The AO undreamed tibial nail:a 14-month follow-up of the 1992 TT experience. Injury,1994, 25(7): 423-425
28. Giannoudis PY, urlong AJ, Macdonald DA, et al.Reamed against unreamed nailing of the femoral diaphysis:a retrospective study of healing time. Injury, 1997,28(1): 15-18
29．刘长贵，张宝中，郭艾，等．带锁髓内钉治疗股骨干骨折并发症及防治，中华骨科杂志，1998,8(12)：725-727
30．徐卫东，张春才，吴岳嵩，等．股骨交锁髓内钉应用的并发症和防治．解放军医学杂志，2000,25(4)：252-254
31. Schemitsch EH, Turchin DC, Kowalski MJ, et al. Quantitative assessment of bone injury and repair after reamed and unreamed locked intramedullary nailing.J Trauma. 1998;45(2):250-255
32. Strecker W.Local complications of intramedullary nailing. Orthopade,1996, 25:270-273
33．杨雍，刘长贵，罗先正．带锁髓内钉治疗股骨干骨折不愈合、延迟愈合．骨与关节损伤杂志，1998,13：269-271
34．印心奇，徐根宝，顾小华，等．交锁髓内钉的临床应用体会．中国矫形外科杂志，1998，5：410-411
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