髌骨骨折张力带内固定有限元模型的建立和分析
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摘要
研究背景
髌骨是人体最大的籽骨,形状为上宽、下尖、前后扁,前面粗糙,其上连接股四头肌,下通过髌韧带连接于胫骨结节。后面为光滑的关节面,与股骨髌面构成髌股关节。髌骨是构成膝关节的骨之一
髌骨位置表浅,只有皮肤、薄层皮下组织及髌前滑囊在髌骨之上,故髌骨易因直接暴力及跌打而受伤。近年来随着科学与技术的发展,生产生活的日益加速,骨折的发生也随之增加。髌骨骨折是临床常见的关节内骨折,占全身骨折的1.65%。
对于分离移位较大的髌骨骨折,较为理想的治疗方法是切开复位内固定手术,其有利于关节的早期活动和膝关节功能的恢复。目前对于髌骨骨折的内固定方法有很多种,常见的方法有克氏针张力带、螺钉钢丝张力带、NT-PC (NiTi-patella concentrator,镍钛-聚髌器)、Cable-pin系统、五角网缝合和丝线荷包缝合等,各有其优缺点。究竟选择哪种较为恰当?
因此如何比较各种内固定的力学性能,为临床选取最佳的手术治疗方案尤为重要。
当前大多数学者从三个方面进行髌骨骨折内固定方式的比较研究。一是对临床病例进行观察及比较研究,大多以Bostman评分标准进行比较,Bostman评分标准包括：关节运动范围的大小、有无疼痛及疼痛程度、对工作的影响、股四头肌的萎缩、是否需手杖、有无关节积液、有无打软腿、爬楼梯是否困难等多方面进行综合评价。该方法主要以临床恢复效果来间接评估髌骨骨折内固定方式的优劣,无法直接了解在相同应力条件下不同髌骨骨折内固定变化程度的差异。二是在新鲜尸体膝关节进行髌骨骨折内固定模拟,进行比较。该方法系正统地对髌骨骨折内固定进行生物力学的研究,可以直接从生物力学角度比较,但在实验方法上仍受到不少制约。比如新鲜尸体标本的来源比较困难；需要专业的生物力学工程实验室；一具尸体标本只能应用一次,不能重复应用,实验成本大；无法直接观察内部克氏针的变形及骨折内部的位移情况；实验结果不够直观形象等。三是理论生物力学研究,即以数学力学模型来进行数值应力分析。
有限元分析即属于理论生物力学研究。与实验生物力学相比,有限元分析具有以下特点：(1)有限元法能在不同状态下进行模拟,得到不受实验条件影响的结果,排除了因为实验条件不同造成的误差。(2)用有限元分析法对模拟体的结构形状、材料性能、边界条件等均可用数学形式概括出来。可重复计算,节约了实验成本。(3)可以很逼真地建立三维模拟实验体的模型,并赋予其生物力学材料特性。通过仿真实验,得到很多其它实验方法无法得到的数据。
由于以上优势,有限元分析在骨科临床研究中得到较广泛地应用,但有关髌骨骨折内固定的有限元研究较少,大多集中在临床病例观察及总结性研究和生物力学研究。
虽然南京大学医学院附属鼓楼医院骨科陈履平等曾在1989年利用平面九节点法对髌骨及张力带内固定以平面问题进行演算,但随着计算机及软件的进一步发展,应用大型有限元软件进行分析无疑比以前更加准确、全面、形象。
为什么对髌骨骨折内固定采用大型有限元软件分析较少,考虑原因在于当前髌骨骨折内固定主要是以张力带内固定的方式,因为固定的钢丝及克氏针均较细小,以CT或MRI直接扫描方式进行重建较困难,若利用大型建模软件进行模拟重建,最难的是建立钢丝张力带,其构建有3个难点：一是钢丝张力带是贴附在髌骨前表面；二是钢丝张力带与克氏针接触的四端,不仅要与髌骨前表面贴附,而且还要与克氏针表面相贴附；三是钢丝结的构建。由于髌骨前方表面本身非常不规则,更增加了构建符合上述标准的钢丝张力带的难度。因此制约了髌骨骨折内固定有限元的研究。
本课题利用先进的计算机辅助建模、分析技术,对成人正常髌骨进行三维建模、模拟髌骨骨折、张力带内固定,克服髌骨骨折张力带内固定的建模难题,成功建立两种不同髌骨骨折张力带内固定有限元模型,并进行有限元分析,探讨应有现代多种大型软件对髌骨骨折内固定进行有限元分析的方法和可行性,并通过有限元分析比较两种髌骨骨折内固定方法的优劣。
目的
1、建立髌骨骨折不同张力带内固定的三维有限元模型,并对所建模型进行有限元力学分析。
2、探讨应用现代多种大型软件对髌骨骨折内固定进行有限元分析的方法和可行性。
3、通过有限元分析比较两种髌骨骨折内固定方法的优劣。
方法
1、髌骨模型的建立：选择1名成年女性志愿者,成年女性志愿者仰卧在CT(Computed tomography,电子计算机断层摄影)扫描台上,使用16层螺旋CT扫描机(SIMENS SENSATION 16)对该志愿者自足底至大腿中段进行薄层扫描,间距1.25mm,共获得489层断层扫描图像。将图像数据以DICOM(Digital imaging and communications in medicine,医学数字成像和通信)格式存入可读写光盘,并导入三维医学图像建模软件Mimics 10.01软件,通过Region growing选择右侧髌骨区域,提取右侧髌骨Polylines,共40层,以IGES (Initial graphics exchange specification,初始化图形交换规范)格式导出后导入Geomagic studio10.0软件进行去噪、封装、光滑化,利用该软件强大的曲面建模功能建立髌骨几何模型。
2、AO/8字形张力带钢丝模型的建立：将Geomagic studio 10.0软件中建立的髌骨几何模型以IGES格式导出后导入Pro/ENGINEER Wildfire 2.0软件中生成髌骨几何体,再利用Pro/ENGINEER Wildfire 2.0软件进行测量,取髌骨横轴分成四等分,纵轴三等分,取外、内1/4,前1/3处作为克氏针固定轴,利用扫描功能,生成两根折弯的克氏针,直径1.5mm,根据AO张力带和8字形张力带中钢丝的捆扎方式分别绘出钢丝曲线,利用扫描混合生成钢丝,钢丝直径0.6mm。
3、髌骨骨折的建立：取纵轴中点,利用Pro/ENGINEER Wildfire 2.0软件,拉伸生成一与髌骨相垂直平面(Z向),进行分割,分别生成平面上段髌骨(近端骨折块)和平面下段髌骨(远端骨折块),模拟髌骨横型骨折。
4、髌骨骨折AO/8字形张力带内固定模型(Pro/E)的建立：将建成的髌骨骨折块、克氏针、捆扎钢丝在Pro/ENGINEER Wildfire 2.0进行装配,生成髌骨骨折AO/8字形张力带内固定模型。
5、髌骨骨折AO/8字形张力带内固定的ANSYS模型的建立：激活ANSYS10.0软件安装选项中包含与Pro/ENGINEER Wildfire 2.0软件的接口模块"Connection for ProEngineer"。将Pro/ENGINEER Wildfire 2.0中的文件直接导入ANSYS 10.0软件中,其中考虑髌骨分为骨皮质和骨松质,为了进行有限元分析时方便建立接触分析,利用Geomagic studio 10.0中的偏移功能,将整个髌骨表面内移1 mm,生成骨松质髌骨模型,在ANSYS 10.0中进行布尔运算,生成骨皮质髌骨模型,将骨皮质髌骨模型与骨松质髌骨模型通过Glue黏合在一起,建立完整的两个髌骨骨折块。将克氏针及缠绕钢丝导入ANSYS 10.0中,进行装配,生成髌骨骨折AO/8字形张力带内固定ANSYS模型。
6、髌骨骨折AO/8字形张力带内固定的有限元模型的建立：按下表对髌骨骨折两种张力带内固定ANSYS模型中各实体进行赋予单元类型及材料参数,进行网格划分,设置接触对。生成髌骨骨折AO/8字形张力带内固定的有限元模型。其中髌骨骨折AO张力带内固定有限元模型总节点数：404343,总单元307719；髌骨骨折8字形张力带内固定有限元模型总节点数：401853,总单元数：296078。
完整髌骨骨折张力带内固定模型单元类型、材料特性表
7、边界条件和荷载的设置
由于髌骨活动度不同关节面接触部分不同,屈膝活动90。时,髌骨关节接触面在髌骨上方,我们固定髌骨上下方约髌韧带大小的部分(对髌骨最下端和最上端髌韧带附着区进行全约束),在髌骨近端骨折块上90。关节面区施加正向压力600N,分析模拟屈膝90。时髌骨骨折两种张力带内固定术后受力后的位移和变形特点。
结果
1、髌骨骨折块应力后向前发生位移(Z正向),自关节面侧(后侧)至前侧,呈大到小变化,因此张力带有明显的Z向加压作用。(Z轴移位是前后移位,正向为向前)
2、髌骨骨折块,无论是在双克氏针平面以上或在双克氏针平面以下,在应力后均以下位移为主(Y负向),因此张力带有明显的对抗股四头肌的向上拉应力作用。(Y轴移位是上下移位,Y轴正向为向上)
3、髌骨骨折块在应力后,虽然在双克氏针平面以上和在双克氏针平面以下的位移云图有所不同,但两者向下移位(Y方向)的绝对值从骨折中心到周围位移均逐渐减少,因此张力带有明显的周围向骨折端及中心加压作用。
4、髌骨骨折块在应力后,在双克氏针平面以下,右侧到左侧(X方向)的位移绝对值由大到零再到大,即有明显的中心向两侧分散作用。而在双克氏针平面以上,虽有明显中心向两侧分散作用,但由于钢丝环扎的作用,两侧又形成两个中心,从中心到周围位移绝对值逐渐减小,有周围向两中心加压作用,起到阻止两侧分散的作用。(X轴移位是右左移位,X轴正向为向左)
5、两枚克氏针存在着明显的变形,其变形以骨折端为中心向两侧递减,起到弹性固定作用,而且两枚克氏针的变形是不对称的。
6、克氏针、钢丝的最大位移主要集中在骨折端上方。
7、克氏针的最大变形位移大于钢丝的最大变形位移,因此张力带充分利用了克氏针折弯要优于钢丝的性能。
8、8字形张力带内固定髌骨骨折在相同荷载下的位移小于AO张力带内固定髌骨骨折。
结论
1、AO/8字形张力带有多向加压作用,可将髌股作用力转化拮抗股四头肌向上的拉应力。
2、对于髌骨横骨折,8字形张力带内固定要优于AO张力带内固定。
3、有限元分析结果与生物力学结果相符,建立的髌骨骨折AO/8字形张力带内固定有限元模型有效；利用现代多种大型软件对髌骨骨折内固定进行有限元分析的方法可行,可通过有限元分析比较髌骨骨折内固定方法的优劣。为临床治疗提供借鉴。
Background
Patella is the maximal sesamoid bones of human body,it is flat,wide top,cuspidal underside and rough anterior surface.It connects quadriceps muscle of thigh from top and tubercle of tibia by patellar tendon.Its back is smooth articular surface which composes patellofemoral joint with patellar fossa of femur.Patella is the one of bones composing knee joint.
Patella is superficial,only a skin,lamellar subcutaneous tissue and bursa synovialis above it,so it is easy to be injured by direct violence and tumble.For the past few years,with the development of science and technology and increasingly acceleration of society,bone fractures have been also increasing.Patellar fracture is frequent,it is 1.65 percent of all bone fractures.
It is a ideal method that operation of open reduction and internal fixation treats patellar fracture with comparatively large dissociation,which is beneficial to early mobilization and rehabilitation of knee joint.Currently,there are many internal fixation methods for treating patellar fracture include tensile force girdle with kirschner wires、NT-PC (NiTi-Patella Concentrator)、Cable-pin system、five-pointed star lattice sutures,the purse string with silk thread,etc.Each has itself advantage and disadvantage,how to select the best?
Accordingly,it is very important that how to compare various kinds of internal fixation methods for selecting the best therapic method.
At present,most of scholars undertake comparative studies of internal fixation methods of patellar fracture from three directions.The first direction is carried out by reviewing the different clinical cases by Bostman score,Bostman score is composed of ROM(range of Joint motion),pain degree,obstructive work degree,auantic degree of quadriceps muscle of thigh,hand crutch Assistance,quantity of hydrops articuli,strength of lower limb,ability of climbing staircase,etc.Which judges the therapeutic effects of internal fixation methods of patellar fracture by clinical bone healing and rehabilitation of knee joint,it is indirect,cann't know displaces after the same force on the postoperative patellar.The second direction is carried out by simulating different internal fixation operations on patellas of cadavers.Which is a standard biomechanical research.lt can measure results after the same force on the postoperative patellars,but it has many shortages,such as difficult cadaveric source,needing good experiment conditions include professional biomechanical engineering laboratory,costly expenses,deficient of observing deformations and offsets of inner bone and kirschner wires,metaphysical results,etc.The third direction is a theoretical biomechanical research.Which has stress analysis of numerical values by mathematical mechano-models.
The finite element analysis (FEA) belongs to the theoretical biomechanical research.In contrast with experimental biomechanics,the finite element analysis has following advantages:(1)The finite element method can have simulations in different conditions,so it gets results that don't be influenced by conditons,namely,it precludes error from different experimental conditions.(2)The finite element analysis method can summarize structural shape,material efficiency and boundary condition of analogue by mathematical pattern,calculate tautologically and save experimental cost.(3)The finite element analysis method can establish three dimensional experimental analogue,then assign its biomechanical material characteristics.in the experiement of simulations,many datas can be gained which cann't in other experimental way.
Owing to above advantages,the finite element analysis is made extensive use of clinical researchs of orthopedics.But on patellar fracture,it is less,most of researchs concentrate on clinical cases'reviews and biomechanics.
Although Chen LP et al carried out calculus for patella fixed with tensile force girdle in planar nine nodes method in 1989,with the further development of computer and his softwares,it is more accurate,comprehensive and iconical to analyse the internal fixations of patella fracture with the finite element by many modern large scale softwares.
Why to study internal fixations of patellar fracture is less in the finite element method?Because the major operative method of treating patella fracture is fixing by tensile force girdle with kirschner wires,both the kirschner wires and steel wire are small,it is very difficult to modeling them by computed tomography or magnetic resonance imaging scanning directly.So the best method is established model by large scale modeling software.There are three difficulties:Firstly,tensile force girdle is attached to surface of patella.Secondly,tensile force girdle is not attached to surface of patella,but to surfaces of two kirschner wires on quadripolar.Thirdly,steel wire tie must be satisfactorily established.On account of very irregular surface of patella,it is more difficult that tensile force gridle as above standardizations is established. Markedly,it restricts the finite element reseach on patella fracture.
On this research,We have established three dimensional model of adult's normal patella,simulated bone fracture,fixed patella fracture with kirschner wires and tensile force girdles by advanced computer-assisted modeling and analytical techniques.We have overcome three difficulties,established the finite-element models of patella fracture fixed with two different tensile force girdles successfully,then have the finite element analysis,investigate feasibility and method to analyse the internal fixations of patella fracture by many modern large scale softwares,compared the two internal fixations simultaneously.
Objective
1.To create finite-element models of patella fracture fixed with two different tensile force girdles and have the finite element mechanical analysis on them.
2.To investigate feasibility and method to analyse the internal fixations of patella fracture with the finite element by many modern large scale softwares.
3.To compared the two internal fixations of patella fracture by the finite element analysis.
Methods
1.Establishment of the model of patella
An adult female volunteer was selected,she was scanned at 1.25mm slice from foots to middle legs by computed tomography machine of SIMENS SENSATION 16,after backlay on the scanner platform of computed tomography machine,then 489 slices of tomoscanning images were gained.
We wrote these images into R/W (readable/writable) compact disc by DICOM(Digital imaging and communications in medicine) format,and imported into the software of Mimics 10.01,selected right region patellaris by Region growing,extracted 40 slices of polylines of right patella,then imported into the software of Geomagic studio 10.0 by IGES (Initial graphics exchange specification) format,reduced noise,wraped polygons,smoothed surfaces,lastly established geometrical model of patella.
2.Establishment of the models of AO and 8 font style tensile force gridle
The geometrical model of patella was imported into the software of Pro/ENGINEER Wildfire 2.0 by IGES format,by measure we divided it into quartering by axis of abscissa and trisection by axis of ordinate,firstly selected front of 1/3,then on the plane,selected outside of 1/4 and inside of 1/4 as axises of kirschner wires,generated two bended kirschner wires by mixed-sweeping function,their diameter was 1.5 millimeter.Finally,curves of steel wires were drawed respectively by winding ways of AO and 8 font style tensile force gridles,generated two bended steel wires by mixed-sweeping function,their diameter was 0.6 millimeter.
3.Establishment of the models of patella fracture
We selected middle point of axis of ordinate,extended a vertical plane (Z direction),then divided the patella into two fractured blocks by the software of Pro/ENGINEER Wildfire 2.0.
4.Establishment of models of patella fracture fixed with AO and 8 font style tensile force girdles
We assembled two patella fractured blocks,two kirschner wires and two bended steel wires into two models of patella fracture fixed with AO and 8 font style tensile force girdles by the software of Pro/ENGINEER Wildfire 2.0.
5.Establishment of ANSYS models of patella fracture fixed with AO and 8 font style tensile force girdles
We activated interface modular of Connection for ProEngineer in the setting options of the soft of ANSYS 10.0,directly imported the documents of Pro/ENGINEER Wildfire 2.0 into the software of ANSYS 10.0,because patella is composed of cortical bone and cancellous bone,we established two sections,offseted inward 1 millimeter,generated model of cancellous patella,by boolean we generated model of cortical patella,then glued them,established two integrated patella fractured blocks.Lastly imported two kirschner wires and two bended steel wires into the software of ANSYS 10.0,assembled them into ANSYS models of patella fracture fixed with AO and 8 font style tensile force girdles.
6.Establishment of finite-element models of patella fracture fixed with AO and 8 font style tensile force girdles
We assigned elemental type and materical parameter to each entity by following table,meshing them,then seted up contact pairs,finally we get finite-element models of patella fracture fixed with AO and 8 font style tensile force girdles.The finite-element model of patella fracture fixed with AO tensile force girdles has 404343 nodes,307719 element units;the finite-element model of patella fracture fixed with 8 font style tensile force girdles has 401853 nodes,296078 element units.
Table of elemental types and materical features in the finite element models of patella fracture fixed with tensile force girdles
7. Settings of boundary condition and loading
Because contiguous articular surface of patella is varied with the range of patella motion,it is the top of patella when the range of patella motion is 90°,we selected and exerted force of 600N from norientation on the section,after wholly constrainted attachment regions of patellar ligament in the two polar of patella,analyzed displacement and deformation features simulating patellofemoral joint under 600 N loading at 90°knee bending.
Results
1.Fractured blocks of patella offsets from post to fore(z norientation) and offset's absolute values gradually diminish after exerted force,accordingly,tensile force girdles have an evident pressure on Z-direction.(positive displace of Z-direction is from post to fore)
2.Fractured blocks of patella wherever above or below two kirschner wires offsets mainly downward(Y-negative direction)after exerted force,accordingly,tensile force girdles have an evident effect against drawing upward from quadriceps muscle of thigh.(positive displace of Y-direction is from below to above)
3.Although Fractured blocks of patella above two kirschner wires have different offset's nephograms from below after exerted force,both of their offset's absolute values (Y-negative direction) gradually diminish from center to environment of bone fracture,accordingly,tensile force girdles have an evident pressure from environment to center.
4.Offset's absolute values of fractured blocks of patella below two kirschner wires from right to left gradually diminish to zero then gradually increase after exerted force,namely,have an evident dispersion from center to two sides.But above two kirschner wires their Offset's absolute values from right to left gradually diminish to zero then gradually increase,namely,have an evident dispersion from center to two sides,simultaneously two sides form two center,absolute values gradually diminish from center to environment,namely,tensile force girdles have an evident pressure from environment to two center,which can prevent two-side dispersion.(positive displace of X-direction is from right to left)
5.Two kirschner wires have marked deformations which gradually diminish from center to environment of bone fracture,two kirschner wires have an role of elastic fixation,furthermore,their deformations are dissymmetrical.
6.Maximum displaces of both kirschner and steer wires concentrate mainly on bone fracture.
7.Maximum displaces of kirschner wires is bigger than of steer wires.Therefore,tensile force girdles make good use of better kirschner wires' bending efficiency than steer wires'
8.Displace of patella fracture fixed with 8 font style tensile force girdles is smaller than with AO's under the same loading.
Conclusions
1.AO/8 font style tensile force girdles can pressurizing on bone fracture from many directions and convert patellofemoral force against drawing upward from quadriceps muscle of thigh.
2.8 font style tensile force girdles is better than AO fixed on transverse fracture of patella.
3.Results of the finite element analysis is coincident with of biomechanics,which confirms that finite-element models of patella fracture fixed with AO and 8 font style tensile force girdles are effective,it is feasible to analyse the internal fixations of patella fracture with the finite element by many modern large scale softwares,we can compared different internal fixations by the finite element analysis and provide clinical instruction.
髌骨是人体最大的籽骨,形状为上宽、下尖、前后扁,前面粗糙,其上连接股四头肌,下通过髌韧带连接于胫骨结节。后面为光滑的关节面,与股骨髌面构成髌股关节。髌骨是构成膝关节的骨之一
髌骨位置表浅,只有皮肤、薄层皮下组织及髌前滑囊在髌骨之上,故髌骨易因直接暴力及跌打而受伤。近年来随着科学与技术的发展,生产生活的日益加速,骨折的发生也随之增加。髌骨骨折是临床常见的关节内骨折,占全身骨折的1.65%。
对于分离移位较大的髌骨骨折,较为理想的治疗方法是切开复位内固定手术,其有利于关节的早期活动和膝关节功能的恢复。目前对于髌骨骨折的内固定方法有很多种,常见的方法有克氏针张力带、螺钉钢丝张力带、NT-PC (NiTi-patella concentrator,镍钛-聚髌器)、Cable-pin系统、五角网缝合和丝线荷包缝合等,各有其优缺点。究竟选择哪种较为恰当?
因此如何比较各种内固定的力学性能,为临床选取最佳的手术治疗方案尤为重要。
当前大多数学者从三个方面进行髌骨骨折内固定方式的比较研究。一是对临床病例进行观察及比较研究,大多以Bostman评分标准进行比较,Bostman评分标准包括：关节运动范围的大小、有无疼痛及疼痛程度、对工作的影响、股四头肌的萎缩、是否需手杖、有无关节积液、有无打软腿、爬楼梯是否困难等多方面进行综合评价。该方法主要以临床恢复效果来间接评估髌骨骨折内固定方式的优劣,无法直接了解在相同应力条件下不同髌骨骨折内固定变化程度的差异。二是在新鲜尸体膝关节进行髌骨骨折内固定模拟,进行比较。该方法系正统地对髌骨骨折内固定进行生物力学的研究,可以直接从生物力学角度比较,但在实验方法上仍受到不少制约。比如新鲜尸体标本的来源比较困难；需要专业的生物力学工程实验室；一具尸体标本只能应用一次,不能重复应用,实验成本大；无法直接观察内部克氏针的变形及骨折内部的位移情况；实验结果不够直观形象等。三是理论生物力学研究,即以数学力学模型来进行数值应力分析。
有限元分析即属于理论生物力学研究。与实验生物力学相比,有限元分析具有以下特点：(1)有限元法能在不同状态下进行模拟,得到不受实验条件影响的结果,排除了因为实验条件不同造成的误差。(2)用有限元分析法对模拟体的结构形状、材料性能、边界条件等均可用数学形式概括出来。可重复计算,节约了实验成本。(3)可以很逼真地建立三维模拟实验体的模型,并赋予其生物力学材料特性。通过仿真实验,得到很多其它实验方法无法得到的数据。
由于以上优势,有限元分析在骨科临床研究中得到较广泛地应用,但有关髌骨骨折内固定的有限元研究较少,大多集中在临床病例观察及总结性研究和生物力学研究。
虽然南京大学医学院附属鼓楼医院骨科陈履平等曾在1989年利用平面九节点法对髌骨及张力带内固定以平面问题进行演算,但随着计算机及软件的进一步发展,应用大型有限元软件进行分析无疑比以前更加准确、全面、形象。
为什么对髌骨骨折内固定采用大型有限元软件分析较少,考虑原因在于当前髌骨骨折内固定主要是以张力带内固定的方式,因为固定的钢丝及克氏针均较细小,以CT或MRI直接扫描方式进行重建较困难,若利用大型建模软件进行模拟重建,最难的是建立钢丝张力带,其构建有3个难点：一是钢丝张力带是贴附在髌骨前表面；二是钢丝张力带与克氏针接触的四端,不仅要与髌骨前表面贴附,而且还要与克氏针表面相贴附；三是钢丝结的构建。由于髌骨前方表面本身非常不规则,更增加了构建符合上述标准的钢丝张力带的难度。因此制约了髌骨骨折内固定有限元的研究。
本课题利用先进的计算机辅助建模、分析技术,对成人正常髌骨进行三维建模、模拟髌骨骨折、张力带内固定,克服髌骨骨折张力带内固定的建模难题,成功建立两种不同髌骨骨折张力带内固定有限元模型,并进行有限元分析,探讨应有现代多种大型软件对髌骨骨折内固定进行有限元分析的方法和可行性,并通过有限元分析比较两种髌骨骨折内固定方法的优劣。
目的
1、建立髌骨骨折不同张力带内固定的三维有限元模型,并对所建模型进行有限元力学分析。
2、探讨应用现代多种大型软件对髌骨骨折内固定进行有限元分析的方法和可行性。
3、通过有限元分析比较两种髌骨骨折内固定方法的优劣。
方法
1、髌骨模型的建立：选择1名成年女性志愿者,成年女性志愿者仰卧在CT(Computed tomography,电子计算机断层摄影)扫描台上,使用16层螺旋CT扫描机(SIMENS SENSATION 16)对该志愿者自足底至大腿中段进行薄层扫描,间距1.25mm,共获得489层断层扫描图像。将图像数据以DICOM(Digital imaging and communications in medicine,医学数字成像和通信)格式存入可读写光盘,并导入三维医学图像建模软件Mimics 10.01软件,通过Region growing选择右侧髌骨区域,提取右侧髌骨Polylines,共40层,以IGES (Initial graphics exchange specification,初始化图形交换规范)格式导出后导入Geomagic studio10.0软件进行去噪、封装、光滑化,利用该软件强大的曲面建模功能建立髌骨几何模型。
2、AO/8字形张力带钢丝模型的建立：将Geomagic studio 10.0软件中建立的髌骨几何模型以IGES格式导出后导入Pro/ENGINEER Wildfire 2.0软件中生成髌骨几何体,再利用Pro/ENGINEER Wildfire 2.0软件进行测量,取髌骨横轴分成四等分,纵轴三等分,取外、内1/4,前1/3处作为克氏针固定轴,利用扫描功能,生成两根折弯的克氏针,直径1.5mm,根据AO张力带和8字形张力带中钢丝的捆扎方式分别绘出钢丝曲线,利用扫描混合生成钢丝,钢丝直径0.6mm。
3、髌骨骨折的建立：取纵轴中点,利用Pro/ENGINEER Wildfire 2.0软件,拉伸生成一与髌骨相垂直平面(Z向),进行分割,分别生成平面上段髌骨(近端骨折块)和平面下段髌骨(远端骨折块),模拟髌骨横型骨折。
4、髌骨骨折AO/8字形张力带内固定模型(Pro/E)的建立：将建成的髌骨骨折块、克氏针、捆扎钢丝在Pro/ENGINEER Wildfire 2.0进行装配,生成髌骨骨折AO/8字形张力带内固定模型。
5、髌骨骨折AO/8字形张力带内固定的ANSYS模型的建立：激活ANSYS10.0软件安装选项中包含与Pro/ENGINEER Wildfire 2.0软件的接口模块"Connection for ProEngineer"。将Pro/ENGINEER Wildfire 2.0中的文件直接导入ANSYS 10.0软件中,其中考虑髌骨分为骨皮质和骨松质,为了进行有限元分析时方便建立接触分析,利用Geomagic studio 10.0中的偏移功能,将整个髌骨表面内移1 mm,生成骨松质髌骨模型,在ANSYS 10.0中进行布尔运算,生成骨皮质髌骨模型,将骨皮质髌骨模型与骨松质髌骨模型通过Glue黏合在一起,建立完整的两个髌骨骨折块。将克氏针及缠绕钢丝导入ANSYS 10.0中,进行装配,生成髌骨骨折AO/8字形张力带内固定ANSYS模型。
6、髌骨骨折AO/8字形张力带内固定的有限元模型的建立：按下表对髌骨骨折两种张力带内固定ANSYS模型中各实体进行赋予单元类型及材料参数,进行网格划分,设置接触对。生成髌骨骨折AO/8字形张力带内固定的有限元模型。其中髌骨骨折AO张力带内固定有限元模型总节点数：404343,总单元307719；髌骨骨折8字形张力带内固定有限元模型总节点数：401853,总单元数：296078。
完整髌骨骨折张力带内固定模型单元类型、材料特性表
7、边界条件和荷载的设置
由于髌骨活动度不同关节面接触部分不同,屈膝活动90。时,髌骨关节接触面在髌骨上方,我们固定髌骨上下方约髌韧带大小的部分(对髌骨最下端和最上端髌韧带附着区进行全约束),在髌骨近端骨折块上90。关节面区施加正向压力600N,分析模拟屈膝90。时髌骨骨折两种张力带内固定术后受力后的位移和变形特点。
结果
1、髌骨骨折块应力后向前发生位移(Z正向),自关节面侧(后侧)至前侧,呈大到小变化,因此张力带有明显的Z向加压作用。(Z轴移位是前后移位,正向为向前)
2、髌骨骨折块,无论是在双克氏针平面以上或在双克氏针平面以下,在应力后均以下位移为主(Y负向),因此张力带有明显的对抗股四头肌的向上拉应力作用。(Y轴移位是上下移位,Y轴正向为向上)
3、髌骨骨折块在应力后,虽然在双克氏针平面以上和在双克氏针平面以下的位移云图有所不同,但两者向下移位(Y方向)的绝对值从骨折中心到周围位移均逐渐减少,因此张力带有明显的周围向骨折端及中心加压作用。
4、髌骨骨折块在应力后,在双克氏针平面以下,右侧到左侧(X方向)的位移绝对值由大到零再到大,即有明显的中心向两侧分散作用。而在双克氏针平面以上,虽有明显中心向两侧分散作用,但由于钢丝环扎的作用,两侧又形成两个中心,从中心到周围位移绝对值逐渐减小,有周围向两中心加压作用,起到阻止两侧分散的作用。(X轴移位是右左移位,X轴正向为向左)
5、两枚克氏针存在着明显的变形,其变形以骨折端为中心向两侧递减,起到弹性固定作用,而且两枚克氏针的变形是不对称的。
6、克氏针、钢丝的最大位移主要集中在骨折端上方。
7、克氏针的最大变形位移大于钢丝的最大变形位移,因此张力带充分利用了克氏针折弯要优于钢丝的性能。
8、8字形张力带内固定髌骨骨折在相同荷载下的位移小于AO张力带内固定髌骨骨折。
结论
1、AO/8字形张力带有多向加压作用,可将髌股作用力转化拮抗股四头肌向上的拉应力。
2、对于髌骨横骨折,8字形张力带内固定要优于AO张力带内固定。
3、有限元分析结果与生物力学结果相符,建立的髌骨骨折AO/8字形张力带内固定有限元模型有效；利用现代多种大型软件对髌骨骨折内固定进行有限元分析的方法可行,可通过有限元分析比较髌骨骨折内固定方法的优劣。为临床治疗提供借鉴。
Background
Patella is the maximal sesamoid bones of human body,it is flat,wide top,cuspidal underside and rough anterior surface.It connects quadriceps muscle of thigh from top and tubercle of tibia by patellar tendon.Its back is smooth articular surface which composes patellofemoral joint with patellar fossa of femur.Patella is the one of bones composing knee joint.
Patella is superficial,only a skin,lamellar subcutaneous tissue and bursa synovialis above it,so it is easy to be injured by direct violence and tumble.For the past few years,with the development of science and technology and increasingly acceleration of society,bone fractures have been also increasing.Patellar fracture is frequent,it is 1.65 percent of all bone fractures.
It is a ideal method that operation of open reduction and internal fixation treats patellar fracture with comparatively large dissociation,which is beneficial to early mobilization and rehabilitation of knee joint.Currently,there are many internal fixation methods for treating patellar fracture include tensile force girdle with kirschner wires、NT-PC (NiTi-Patella Concentrator)、Cable-pin system、five-pointed star lattice sutures,the purse string with silk thread,etc.Each has itself advantage and disadvantage,how to select the best?
Accordingly,it is very important that how to compare various kinds of internal fixation methods for selecting the best therapic method.
At present,most of scholars undertake comparative studies of internal fixation methods of patellar fracture from three directions.The first direction is carried out by reviewing the different clinical cases by Bostman score,Bostman score is composed of ROM(range of Joint motion),pain degree,obstructive work degree,auantic degree of quadriceps muscle of thigh,hand crutch Assistance,quantity of hydrops articuli,strength of lower limb,ability of climbing staircase,etc.Which judges the therapeutic effects of internal fixation methods of patellar fracture by clinical bone healing and rehabilitation of knee joint,it is indirect,cann't know displaces after the same force on the postoperative patellar.The second direction is carried out by simulating different internal fixation operations on patellas of cadavers.Which is a standard biomechanical research.lt can measure results after the same force on the postoperative patellars,but it has many shortages,such as difficult cadaveric source,needing good experiment conditions include professional biomechanical engineering laboratory,costly expenses,deficient of observing deformations and offsets of inner bone and kirschner wires,metaphysical results,etc.The third direction is a theoretical biomechanical research.Which has stress analysis of numerical values by mathematical mechano-models.
The finite element analysis (FEA) belongs to the theoretical biomechanical research.In contrast with experimental biomechanics,the finite element analysis has following advantages:(1)The finite element method can have simulations in different conditions,so it gets results that don't be influenced by conditons,namely,it precludes error from different experimental conditions.(2)The finite element analysis method can summarize structural shape,material efficiency and boundary condition of analogue by mathematical pattern,calculate tautologically and save experimental cost.(3)The finite element analysis method can establish three dimensional experimental analogue,then assign its biomechanical material characteristics.in the experiement of simulations,many datas can be gained which cann't in other experimental way.
Owing to above advantages,the finite element analysis is made extensive use of clinical researchs of orthopedics.But on patellar fracture,it is less,most of researchs concentrate on clinical cases'reviews and biomechanics.
Although Chen LP et al carried out calculus for patella fixed with tensile force girdle in planar nine nodes method in 1989,with the further development of computer and his softwares,it is more accurate,comprehensive and iconical to analyse the internal fixations of patella fracture with the finite element by many modern large scale softwares.
Why to study internal fixations of patellar fracture is less in the finite element method?Because the major operative method of treating patella fracture is fixing by tensile force girdle with kirschner wires,both the kirschner wires and steel wire are small,it is very difficult to modeling them by computed tomography or magnetic resonance imaging scanning directly.So the best method is established model by large scale modeling software.There are three difficulties:Firstly,tensile force girdle is attached to surface of patella.Secondly,tensile force girdle is not attached to surface of patella,but to surfaces of two kirschner wires on quadripolar.Thirdly,steel wire tie must be satisfactorily established.On account of very irregular surface of patella,it is more difficult that tensile force gridle as above standardizations is established. Markedly,it restricts the finite element reseach on patella fracture.
On this research,We have established three dimensional model of adult's normal patella,simulated bone fracture,fixed patella fracture with kirschner wires and tensile force girdles by advanced computer-assisted modeling and analytical techniques.We have overcome three difficulties,established the finite-element models of patella fracture fixed with two different tensile force girdles successfully,then have the finite element analysis,investigate feasibility and method to analyse the internal fixations of patella fracture by many modern large scale softwares,compared the two internal fixations simultaneously.
Objective
1.To create finite-element models of patella fracture fixed with two different tensile force girdles and have the finite element mechanical analysis on them.
2.To investigate feasibility and method to analyse the internal fixations of patella fracture with the finite element by many modern large scale softwares.
3.To compared the two internal fixations of patella fracture by the finite element analysis.
Methods
1.Establishment of the model of patella
An adult female volunteer was selected,she was scanned at 1.25mm slice from foots to middle legs by computed tomography machine of SIMENS SENSATION 16,after backlay on the scanner platform of computed tomography machine,then 489 slices of tomoscanning images were gained.
We wrote these images into R/W (readable/writable) compact disc by DICOM(Digital imaging and communications in medicine) format,and imported into the software of Mimics 10.01,selected right region patellaris by Region growing,extracted 40 slices of polylines of right patella,then imported into the software of Geomagic studio 10.0 by IGES (Initial graphics exchange specification) format,reduced noise,wraped polygons,smoothed surfaces,lastly established geometrical model of patella.
2.Establishment of the models of AO and 8 font style tensile force gridle
The geometrical model of patella was imported into the software of Pro/ENGINEER Wildfire 2.0 by IGES format,by measure we divided it into quartering by axis of abscissa and trisection by axis of ordinate,firstly selected front of 1/3,then on the plane,selected outside of 1/4 and inside of 1/4 as axises of kirschner wires,generated two bended kirschner wires by mixed-sweeping function,their diameter was 1.5 millimeter.Finally,curves of steel wires were drawed respectively by winding ways of AO and 8 font style tensile force gridles,generated two bended steel wires by mixed-sweeping function,their diameter was 0.6 millimeter.
3.Establishment of the models of patella fracture
We selected middle point of axis of ordinate,extended a vertical plane (Z direction),then divided the patella into two fractured blocks by the software of Pro/ENGINEER Wildfire 2.0.
4.Establishment of models of patella fracture fixed with AO and 8 font style tensile force girdles
We assembled two patella fractured blocks,two kirschner wires and two bended steel wires into two models of patella fracture fixed with AO and 8 font style tensile force girdles by the software of Pro/ENGINEER Wildfire 2.0.
5.Establishment of ANSYS models of patella fracture fixed with AO and 8 font style tensile force girdles
We activated interface modular of Connection for ProEngineer in the setting options of the soft of ANSYS 10.0,directly imported the documents of Pro/ENGINEER Wildfire 2.0 into the software of ANSYS 10.0,because patella is composed of cortical bone and cancellous bone,we established two sections,offseted inward 1 millimeter,generated model of cancellous patella,by boolean we generated model of cortical patella,then glued them,established two integrated patella fractured blocks.Lastly imported two kirschner wires and two bended steel wires into the software of ANSYS 10.0,assembled them into ANSYS models of patella fracture fixed with AO and 8 font style tensile force girdles.
6.Establishment of finite-element models of patella fracture fixed with AO and 8 font style tensile force girdles
We assigned elemental type and materical parameter to each entity by following table,meshing them,then seted up contact pairs,finally we get finite-element models of patella fracture fixed with AO and 8 font style tensile force girdles.The finite-element model of patella fracture fixed with AO tensile force girdles has 404343 nodes,307719 element units;the finite-element model of patella fracture fixed with 8 font style tensile force girdles has 401853 nodes,296078 element units.
Table of elemental types and materical features in the finite element models of patella fracture fixed with tensile force girdles
7. Settings of boundary condition and loading
Because contiguous articular surface of patella is varied with the range of patella motion,it is the top of patella when the range of patella motion is 90°,we selected and exerted force of 600N from norientation on the section,after wholly constrainted attachment regions of patellar ligament in the two polar of patella,analyzed displacement and deformation features simulating patellofemoral joint under 600 N loading at 90°knee bending.
Results
1.Fractured blocks of patella offsets from post to fore(z norientation) and offset's absolute values gradually diminish after exerted force,accordingly,tensile force girdles have an evident pressure on Z-direction.(positive displace of Z-direction is from post to fore)
2.Fractured blocks of patella wherever above or below two kirschner wires offsets mainly downward(Y-negative direction)after exerted force,accordingly,tensile force girdles have an evident effect against drawing upward from quadriceps muscle of thigh.(positive displace of Y-direction is from below to above)
3.Although Fractured blocks of patella above two kirschner wires have different offset's nephograms from below after exerted force,both of their offset's absolute values (Y-negative direction) gradually diminish from center to environment of bone fracture,accordingly,tensile force girdles have an evident pressure from environment to center.
4.Offset's absolute values of fractured blocks of patella below two kirschner wires from right to left gradually diminish to zero then gradually increase after exerted force,namely,have an evident dispersion from center to two sides.But above two kirschner wires their Offset's absolute values from right to left gradually diminish to zero then gradually increase,namely,have an evident dispersion from center to two sides,simultaneously two sides form two center,absolute values gradually diminish from center to environment,namely,tensile force girdles have an evident pressure from environment to two center,which can prevent two-side dispersion.(positive displace of X-direction is from right to left)
5.Two kirschner wires have marked deformations which gradually diminish from center to environment of bone fracture,two kirschner wires have an role of elastic fixation,furthermore,their deformations are dissymmetrical.
6.Maximum displaces of both kirschner and steer wires concentrate mainly on bone fracture.
7.Maximum displaces of kirschner wires is bigger than of steer wires.Therefore,tensile force girdles make good use of better kirschner wires' bending efficiency than steer wires'
8.Displace of patella fracture fixed with 8 font style tensile force girdles is smaller than with AO's under the same loading.
Conclusions
1.AO/8 font style tensile force girdles can pressurizing on bone fracture from many directions and convert patellofemoral force against drawing upward from quadriceps muscle of thigh.
2.8 font style tensile force girdles is better than AO fixed on transverse fracture of patella.
3.Results of the finite element analysis is coincident with of biomechanics,which confirms that finite-element models of patella fracture fixed with AO and 8 font style tensile force girdles are effective,it is feasible to analyse the internal fixations of patella fracture with the finite element by many modern large scale softwares,we can compared different internal fixations by the finite element analysis and provide clinical instruction.
引文
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