高屈曲状态下膝关节生物力学研究
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摘要
目的：探讨正常膝关节在完全负重条件下由完全伸直到最大屈曲运动过程中，膝关节相对运动、关节软骨接触轨迹和主要韧带结构的生物力学特性。
方法：健康成年志愿者8人（8个膝关节；年龄：23~49岁；6男2女；体重指数（Body Mass Index, BMI)：19.9~29.3kg/m2），无任何膝关节受伤史或慢性疼痛史。每位受试者均签署知情同意书。本研究通过麻省总医院伦理委员会审查批准。受试膝关节接受MRI扫描，根据MRI建立膝关节髌骨、胫骨及股骨的三维模型，模型包括髌股关节软骨、胫股关节软骨以及前、后交叉韧带（ACL, PCL）、内侧副韧带浅层（sMCL）和深层（dMCL）及外侧副韧带（LCL）的附着点。根据功能解剖，将ACL分为前内侧束（AMB）和后外侧束（PLB），PCL分成前外侧束（ALB）和后内侧束（PMB）。将sMCL、dMCL和LCL按纤维走行，分别平均分成三部分，包括：前束（AB）、中间束（MB）和后束（PB）。模型建立完成后，所有受试者在双荧光成像系统的正交双“C”型臂之间进行准静态单足下蹲动作（每屈曲15°停顿一次），嘱每位受试者均尽可能使膝关节达到最大屈曲。将膝关节3D模型与双荧光成像系统图像整合，重建体内膝关节屈伸运动。随着膝关节由完全伸直到最大屈曲的过程，记录并计算膝关节在每个观测点6个自由度的相对运动参数、关节软骨的接触点坐标（取胫骨平台上所投影关节软骨接触面的几何中心作为软骨接触点）及主要韧带结构不同束支的长度变化（应用MATLAB软件脚本计算出膝关节主要韧带结构各束支的长度变化）。定义膝关节完全伸直时的各束支长度为初始长度。将膝关节由完全伸直到最大屈曲的运动过程按屈曲度分为以下三个范围：①低屈曲度（fullextension~30°）；②中屈曲度（30°~120°）；③高屈曲度（120°~maximal flexion）。使用Repeated measure ANOVA方法分析在不同屈曲角度及屈曲范围内，胫股关节的相对运动参数、软骨接触点坐标及主要韧带结构的长度变化的差异是否有统计学意义。
结果：膝关节由完全伸直到最大屈曲过程中，股骨持续后移。膝关节屈曲FE~30°时，股骨轻度外移、胫骨内旋、内翻；在屈曲30°~120°时，股骨轻度内移、胫骨内翻而内、外旋转变化较小；在120°~MaxF时，股骨迅速内移、胫骨迅速内旋并在最大屈曲度时轻度外翻。膝关节屈曲小于120°时，膝关节内、外侧间室的软骨接触轨迹类似，但是超过屈曲120°后，内侧软骨接触点后移小于外侧。在膝关节屈曲30°~120°时，ACL的长度缩短量较大，在高屈曲度时较小；在膝关节屈曲90°左右，PCL的伸长量最大。随着屈曲角度增大，内、外侧副韧带的前束（AB）均不同程度的延长，除了内侧副韧带浅层（sMCL）的AB在最大屈曲度时缩短；内、外侧副韧带的中间束（MB）在整个膝关节屈伸运动过程中长度变化最小，除了sMCL的MB随着屈曲角度增大而逐渐缩短；所有的后束（PB）随着屈曲角度增大而逐渐缩短。
结论：在整个屈伸过程中，尤其在高屈曲度，膝关节的相对运动、关节软骨接触轨迹及主要韧带结构的长度变化无法用单一的规律来描述。本研究的结果对高屈曲型假体、交叉韧带保留型假体的设计和改进及膝关节伤后康复计划有重要的指导意义。
Purpose: The objective of this study is to investigate the6-DOF kinematics,tibiofemoral cartilage contact biomechanics and the changes in length of the majorligaments of the knee during weight bearing flexion from full extension to maximal flexionof living subjects.
Methods: Eight healthy subjects (eight knees; age,23～49;6male and2female; BMI,19.9～29.3kg/m2) with no history of knee injuries or chronic knee pain were recruited.Each subject signed a consent form approved by the IRB of Massachusetts GeneralHospital. The knees were MRI scanned to create3D models of the patella, tibia and femur,including the articular cartilage of the patella, tibia and femur and the insertions of theACL, PCL, sMCL, dMCL and LCL. Base on the functional anatomy, the ACL was dividedinto two bundles: the anteromedial bundle (AMB) and posterolateral bundle (PLB).Similarly, the PCL was divided into two bundles: the anterolateral bundle (ALB) andposteromedial bundle (PMB). The sMCL, dMCL and LCL were each divided into threeequal portions: the anterior bundle (AB), the middle bundle (MB) and the posterior bundle(PB). The subjects were then imaged using a dual fluoroscopic image system in twoorthogonal directions while performing a quasi-static single-leg lunge （every15°）fromfull extension to the maximal flexion they could perform. The knee models andfluoroscopic images were used to reproduce the in vivo motion of the knee. The6-DOFkinematics, the motion of articular cartilage contact points and the elongation of eachbundle of the major ligaments were measured along the flexion path of the knee. Thecontact points on the medial and lateral tibial plateau were calculated by finding thecentroid of the intersection of the tibial cartilage layers. A mathematical algorithm wasimplemented to find the shortest3D wrapping path of a ligament bundle around the bones.The length of each bundle at the full extension was set as the initial length. The flexionpath of the knee was divided into three ranges: low flexion range (full extension to30°offlexion), middle flexion range (30°to120°of flexion); high flexion range (120°tomaximal flexion). A repeated measure ANOVA was used to detect statistically significantdifferences in the6-DOF kinematics, the motion of articular cartilage contact points andthe bundles at different flexion angles and ranges.
Results: The posterior femoral translation consistently increased from full extension tothe maximum flexion. The lateral femoral translation increased slightly and internal tibialrotation and varus increased at low flexion angles (full extension to30°), the medialfemoral translation and the internal tibial rotation maintained a small variation, and thetibial varus consistently increased in the middle range of flexion (30°to120°), and thenmedial femoral translation and internal tibial rotation sharply increased, and tibia varussharply decreased at high flexion angles (120°to maximal flexion). The contact pointmoved similarly in the medial and lateral compartments before120°of flexion, but less onthe medial compartment at high flexion angles. The ACL was shown to have largerreduction in length at mid-range of flexion and less reduction at maximal flexion. The PCLwas shown to have maximal increase in length around90°of flexion. For collateralligaments, all AB bundles were shown to have increasing length with flexion except that ofthe sMCL showing reduction in length at high flexion. The MB bundles showed minimalchange in lengths except that of the sMCL showing consistent reduction in length withflexion. All PB bundles showed reduction in lengths with flexion.
Conclusions: The results indicated that the knee motion couldn’t be described usingone character in the entire range of flexion, especially in high flexion. The kneebiomechanical data in the entire range of flexion of the knee could be instrumental fordesigning new knee prostheses to achieve physical high flexion, designing anddevelopment of cruciate retaining total knee arthroplasty and improving rehabilitationprotocols after knee injuries.
方法：健康成年志愿者8人（8个膝关节；年龄：23~49岁；6男2女；体重指数（Body Mass Index, BMI)：19.9~29.3kg/m2），无任何膝关节受伤史或慢性疼痛史。每位受试者均签署知情同意书。本研究通过麻省总医院伦理委员会审查批准。受试膝关节接受MRI扫描，根据MRI建立膝关节髌骨、胫骨及股骨的三维模型，模型包括髌股关节软骨、胫股关节软骨以及前、后交叉韧带（ACL, PCL）、内侧副韧带浅层（sMCL）和深层（dMCL）及外侧副韧带（LCL）的附着点。根据功能解剖，将ACL分为前内侧束（AMB）和后外侧束（PLB），PCL分成前外侧束（ALB）和后内侧束（PMB）。将sMCL、dMCL和LCL按纤维走行，分别平均分成三部分，包括：前束（AB）、中间束（MB）和后束（PB）。模型建立完成后，所有受试者在双荧光成像系统的正交双“C”型臂之间进行准静态单足下蹲动作（每屈曲15°停顿一次），嘱每位受试者均尽可能使膝关节达到最大屈曲。将膝关节3D模型与双荧光成像系统图像整合，重建体内膝关节屈伸运动。随着膝关节由完全伸直到最大屈曲的过程，记录并计算膝关节在每个观测点6个自由度的相对运动参数、关节软骨的接触点坐标（取胫骨平台上所投影关节软骨接触面的几何中心作为软骨接触点）及主要韧带结构不同束支的长度变化（应用MATLAB软件脚本计算出膝关节主要韧带结构各束支的长度变化）。定义膝关节完全伸直时的各束支长度为初始长度。将膝关节由完全伸直到最大屈曲的运动过程按屈曲度分为以下三个范围：①低屈曲度（fullextension~30°）；②中屈曲度（30°~120°）；③高屈曲度（120°~maximal flexion）。使用Repeated measure ANOVA方法分析在不同屈曲角度及屈曲范围内，胫股关节的相对运动参数、软骨接触点坐标及主要韧带结构的长度变化的差异是否有统计学意义。
结果：膝关节由完全伸直到最大屈曲过程中，股骨持续后移。膝关节屈曲FE~30°时，股骨轻度外移、胫骨内旋、内翻；在屈曲30°~120°时，股骨轻度内移、胫骨内翻而内、外旋转变化较小；在120°~MaxF时，股骨迅速内移、胫骨迅速内旋并在最大屈曲度时轻度外翻。膝关节屈曲小于120°时，膝关节内、外侧间室的软骨接触轨迹类似，但是超过屈曲120°后，内侧软骨接触点后移小于外侧。在膝关节屈曲30°~120°时，ACL的长度缩短量较大，在高屈曲度时较小；在膝关节屈曲90°左右，PCL的伸长量最大。随着屈曲角度增大，内、外侧副韧带的前束（AB）均不同程度的延长，除了内侧副韧带浅层（sMCL）的AB在最大屈曲度时缩短；内、外侧副韧带的中间束（MB）在整个膝关节屈伸运动过程中长度变化最小，除了sMCL的MB随着屈曲角度增大而逐渐缩短；所有的后束（PB）随着屈曲角度增大而逐渐缩短。
结论：在整个屈伸过程中，尤其在高屈曲度，膝关节的相对运动、关节软骨接触轨迹及主要韧带结构的长度变化无法用单一的规律来描述。本研究的结果对高屈曲型假体、交叉韧带保留型假体的设计和改进及膝关节伤后康复计划有重要的指导意义。
Purpose: The objective of this study is to investigate the6-DOF kinematics,tibiofemoral cartilage contact biomechanics and the changes in length of the majorligaments of the knee during weight bearing flexion from full extension to maximal flexionof living subjects.
Methods: Eight healthy subjects (eight knees; age,23～49;6male and2female; BMI,19.9～29.3kg/m2) with no history of knee injuries or chronic knee pain were recruited.Each subject signed a consent form approved by the IRB of Massachusetts GeneralHospital. The knees were MRI scanned to create3D models of the patella, tibia and femur,including the articular cartilage of the patella, tibia and femur and the insertions of theACL, PCL, sMCL, dMCL and LCL. Base on the functional anatomy, the ACL was dividedinto two bundles: the anteromedial bundle (AMB) and posterolateral bundle (PLB).Similarly, the PCL was divided into two bundles: the anterolateral bundle (ALB) andposteromedial bundle (PMB). The sMCL, dMCL and LCL were each divided into threeequal portions: the anterior bundle (AB), the middle bundle (MB) and the posterior bundle(PB). The subjects were then imaged using a dual fluoroscopic image system in twoorthogonal directions while performing a quasi-static single-leg lunge （every15°）fromfull extension to the maximal flexion they could perform. The knee models andfluoroscopic images were used to reproduce the in vivo motion of the knee. The6-DOFkinematics, the motion of articular cartilage contact points and the elongation of eachbundle of the major ligaments were measured along the flexion path of the knee. Thecontact points on the medial and lateral tibial plateau were calculated by finding thecentroid of the intersection of the tibial cartilage layers. A mathematical algorithm wasimplemented to find the shortest3D wrapping path of a ligament bundle around the bones.The length of each bundle at the full extension was set as the initial length. The flexionpath of the knee was divided into three ranges: low flexion range (full extension to30°offlexion), middle flexion range (30°to120°of flexion); high flexion range (120°tomaximal flexion). A repeated measure ANOVA was used to detect statistically significantdifferences in the6-DOF kinematics, the motion of articular cartilage contact points andthe bundles at different flexion angles and ranges.
Results: The posterior femoral translation consistently increased from full extension tothe maximum flexion. The lateral femoral translation increased slightly and internal tibialrotation and varus increased at low flexion angles (full extension to30°), the medialfemoral translation and the internal tibial rotation maintained a small variation, and thetibial varus consistently increased in the middle range of flexion (30°to120°), and thenmedial femoral translation and internal tibial rotation sharply increased, and tibia varussharply decreased at high flexion angles (120°to maximal flexion). The contact pointmoved similarly in the medial and lateral compartments before120°of flexion, but less onthe medial compartment at high flexion angles. The ACL was shown to have largerreduction in length at mid-range of flexion and less reduction at maximal flexion. The PCLwas shown to have maximal increase in length around90°of flexion. For collateralligaments, all AB bundles were shown to have increasing length with flexion except that ofthe sMCL showing reduction in length at high flexion. The MB bundles showed minimalchange in lengths except that of the sMCL showing consistent reduction in length withflexion. All PB bundles showed reduction in lengths with flexion.
Conclusions: The results indicated that the knee motion couldn’t be described usingone character in the entire range of flexion, especially in high flexion. The kneebiomechanical data in the entire range of flexion of the knee could be instrumental fordesigning new knee prostheses to achieve physical high flexion, designing anddevelopment of cruciate retaining total knee arthroplasty and improving rehabilitationprotocols after knee injuries.
引文
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