国人正常肱骨头形态学与假体设计的相关研究

目的:测量国人肱骨头相关解剖数据,为设计适合中国人的肱骨头假体提供参考值.方法:100根成对防腐肱骨(男28对,女22对),用CT软件测量头心-干轴距、头干角、头-结节高度差、头半径、关节面张角等共13项参数.结果:所得数据行统计学处理,得出各参数分布规律及其间的相关性,性别间比较有显著差异,而左右间差异不显著,除头干角比西方人稍大外,其余参数均较西方人小,差异有非常显著性意义(P＜0.01).结论:有必要设计符合国人肱骨解剖特点的假体.     

不同位置内外上髁轴线对多层螺旋CT容积再现测量肱骨头扭转角的影响

[目的]探讨肱骨远端不同位置内外上髁轴线对多层螺旋CT容积再现三维重建测量肱骨头扭转角的影响。[方法]收集51根肱骨干标本,行16排螺旋CT扫描,容积再现技术三维重建测量肱骨头扭转角。俯视位观察,肱骨远端内外上髁连线取3种不同方位,求得3组肱骨头扭转角。与二维CT取肱骨远端3个不同平面的肱骨头扭转角进行对比研究。[结果]肱骨头扭转角最小值4°,最大值59.8°,6组肱骨头扭转角数据为(25.5±10.2)°,(25.0±10.8)°,(25.7±10.8)°,(27.3±10.3)°,(26.3±10.2)°,(25.8±10.4)°,经统计学处理6组肱骨头扭转角差异不显著。且二维CT测量肱骨头扭转角时肱骨远端层面越向远端值越小。[结论]肱骨头扭转角变异较大,肩关节假体扭转角设计应个性化;肱骨远端不同位置内外上髁轴线对多层螺旋CT容积再现测量肱骨头扭转角没有影响;俯视位观察肱骨,当外上髁露出呈小三角形、肱骨远端前关节面被肱骨头遮盖重叠的位置是多层螺旋CT三维重建测量肱骨头扭转角的更简单、更快捷而且准确的测量位置。     

国人正常股骨CT测量与假体设计的相关研究

目的：本文报告１１０例国人正常股骨ＣＴ测量与假体设计的相关研究。方法：双下肢取中立位，行股骨横断面和全长ＣＴ扫描。由ＣＴ软件测量股骨长度，股骨头直径，头位置，头心－干轴梗距，颈干角，转子部髓腔最大冠、矢状径１６项参数。结果：所得数据行统计学处理，得出各参数分布规律和其间的相关性，并与白种人相应参数比较。各髓腔径小于白种人的参数值，髓腔冠状径、头心－干轴距、股骨头位置与白种人的参数比较，差异有非常显     

国人髌骨形态学研究及其在髌骨假体设计中的意义

目的通过研究正常国人髌骨关节面的形态学特征,探讨它们在国人髌股关节假体的髌骨假体设计中的意义。方法通过影像学方法对国人髌骨的Wiberg分型进行流行病学统计分析,并将国人统计学结果和西方人数据进行比较。结果200例国人髌骨的Wiberg分型结果为:Ⅰ型23例占11·5%,Ⅱ型占128例64%,Ⅲ型42例占21%,Ⅳ型7例占3·5%,在国人髌骨中WibergⅡ型占大多数,WibergⅠ型只占少部分。结论在国人髌股关节假体设计过程中,髌骨假体的形态以WibergⅡ型为模板采取偏心型设计更符合国人髌骨形态学特征。     

健康成人肱骨远端的CT解剖形态学特征

目的探讨健康成人肱骨远端的CT解剖形态学特征及性别差异,为肱骨远端植入物的设计提供参考。方法从医院图像存档与传输系统中选取121例正常肘关节CT图像,于AW4.5工作站中进行重建和测量。通过屈戌轴和肱骨干确定冠状面和水平面,与屈戌轴垂直的面确定为矢状面。于冠状面上测量肱轴角;取四个不同的矢状面测量肱骨小头高度、外侧滑车缘高度、滑车沟高度、内侧滑车缘高度;于水平面上测量肱骨小头宽度、肱骨小头前距、外侧滑车缘前宽、外侧滑车缘后宽、滑车宽度、内侧滑车缘前宽、内侧滑车缘后宽、滑车沟前后距、外侧滑车缘前距、外侧滑车缘后距、内侧滑车缘前距、内侧滑车缘后距、肱骨远端宽度。分析测量参数的性别差异、数据间的相关性及肱轴角与90°的差异。结果男性肱骨小头高度为(21.5±1.3)mm、肱骨小头宽度为(17.5±1.1)mm、肱骨小头前距为(10.8±0.9)mm、滑车宽度为(25.1±2.2)mm、滑车沟高度为(17.3±1.5)mm、滑车沟前后距为(17.5±1.4)mm、外侧滑车缘前宽为(7.7±1.2)mm、外侧滑车缘后宽为(12.5±1.6)mm、内侧滑车缘前宽为(12.4±1.6)mm、内侧滑车缘后宽为(9.8±2.0)mm、外侧滑车缘前距为(10.0±0.8)mm、外侧滑车缘后距为(16.3±1.4)mm、内侧滑车缘前距为(12.9±1.4)mm、内侧滑车缘后距为(13.2±1.4)mm、外侧滑车缘高度为(20.6±1.3)mm、内侧滑车缘高度为(25.0±2.4)mm、肱骨远端宽度为(42.6±2.5)mm,女性分别为(18.7±1.1)mm、(15.3±1.1)mm、(9.5±0.6)mm、(21.7±1.5)mm、(15.4±1.7)mm、(15.6±1.5)mm、(6.8±1.3)mm、(10.7±1.4)mm、(10.6±1.4)mm、(8.5±1.4)mm、(8.9±0.8)mm、(14.5±1.1)mm、(11.4±1.1)mm、(11.5±1.0)mm、(18.1±1.4)mm、(21.6±1.4)mm、(37.0±1.8)mm,男性均大于女性,差异有统计学意义(P<0.05)。肱轴角(男87.4°±3.5°,女87.8°±3.3°)、肱骨小头宽度与肱骨小头高度比(男0.8±0.1,女0.8±0.1)、滑车宽度与肱骨小头宽度比(男1.4±0.2,女1.4±0.1)、内外侧滑车缘高度比(男1.2±0.1,女1.2±0.1)、内侧滑车缘前宽与滑车宽度比(男0.5±0.1,女0.5±0.1)、内侧滑车缘后宽与滑车宽度比(男0.4±0.1,女0.4±0.1)、外侧滑车缘前宽与滑车宽度比(男0.3±0.0,女0.3±0.1)、外侧滑车缘后宽与滑车宽度比(男0.5±0.1,女0.5±0.1)的性别差异无统计学意义(P>0.05)。各项参数除肱轴角外均与肱骨远端宽度呈正相关,随肱骨远端宽度的增大而增大(r值0.335~0.928,P<0.05)。肱轴角(87.6°±3.4°)与90°的差异有统计学意义(t=-7.287,P<0.05)。结论男性肱骨远端尺寸略大于女性,但形状无差异。关节宽度可以作为一个衡量肱骨远端大小的指标,肱骨骨干更偏向于桡侧。     

国人儿童正常肾动脉的多排螺旋CT测量

目的通过观测儿童正常肾动脉CT图像,得到不同年龄段儿童的肾动脉正常值。方法选取腹部CT增强扫描检查无肾脏疾病及其他相关疾病的儿童284名,按年龄分为5组,观测肾动脉支数、肾动脉起始位置、肾动脉主干与腹主动脉下夹角、肾动脉起始处内径、副肾动脉数目、副肾动脉起源、副肾动脉入肾部位,并进行统计分析。结果肾动脉以单支型最多见;右侧肾动脉高于左侧者较为常见;随着年龄增长,肾动脉起点与腹腔干距离逐渐增加（P〈0.05）;肾动脉干与腹主动脉下夹角在不同组间差异无统计学意义（P〉0.05）;各年龄组肾动脉干起始部内径的差异有统计学意义（P〈0.001）,随年龄增长,肾动脉干起始部内径增加,不同性别及左、右肾间差异无统计学意义（P〉0.05）;副肾动脉出现率为35.21%（100/284）,主要起源于肾动脉（66/134,49.25%）及腹主动脉（62/134,46.27%）,经肾上端（98/134,73.13%）及肾下端（28/134,20.90%）入肾。结论本研究初步得到不同年龄儿童肾动脉的相关正常值,有助于诊治儿童肾动脉相关疾病。     

胫骨近端截骨面与胫骨假体的数字化形态学研究

目的 利用数字化技术获取健康成人正常胫骨近端截而及假体的参数参考值,探讨适合不同人种且具有性别差异的胫骨假体设计.方法 对55名志愿者中的92侧正常膝关节(男42侧,女50侧)进行螺旋CT扫描,将断层扣描数据导入Mimics10.1软件建立膝关节三维数字模型,然后将模型导入Geomagic Studio 8软件系统对胫骨近端模型进行模拟截骨、形态学测量,分析不同性别胫骨近端截面的形态学差异.再将获得的模型与通过激光扫描获得的假体(PFC和Nexgen)三维模型进行模拟装配、参数测量.结果 胫骨近端截骨面的前后径(AP)为(49.87 ±3.90)mm、内外侧横径(ML)为(73.50±5.60)mm,AP与ML呈正相关.男性胫骨平台AP为(53.24±4.10)mm、ML为(75.85±3.50)mm,均比女性[AP为(47.61±3,70)mm,ML为(67.68±2.60)mm]大.内侧前后径(MAP)比外侧前后径(LAP)大,男性平均大(3.90±2.90)mm,女性平均大(3.70±2.70)mm.PFC假体(0.75±0.05)和Nexgen假体(0.69±0.03)的AP/MP比值与本研究正常成人(0.68±0.03)相比,差异均有统计学意义(P<0.05).结论 不同性别及人种的胫骨截面形态存在显著差异,为提高人工膝关节胫骨假体的覆盖率,胫骨假体设计及临床操作均要考虑不同人种和性别的形态学特点.     

髋关节股骨假体远端中心化状态的定量评估

目的采用CT成像技术评估髋关节置换术后股骨假体远端的中心化状态。方法对18个人工全髋关节股骨假体柄的第4区进行CT扫描,并以股骨髓腔中心为原点,以股骨远端内外后髁连线的平行线作为X轴,建立直角坐标系,对假体柄远端进行测量分析。结果通过CT扫描可以更直观、准确地显示假体柄远端在骨髓腔中的位置。测量所得的圆心距(假体柄远端中心点与股骨髓腔中心点的距离)、股骨髓腔半径以及假体柄尖所在的象限和象限值,可以作为股骨假体远端中心化状态的量化指标。结论由于CT扫描的介入,可以对股骨假体远端中心化状态进行量化观察,为指导临床医生研究和改进手术技术,判断术后临床效果,提供了一种准确、量化的评估方法,也为相关研究提供了可靠的基础。     

国人肱骨近端三维解剖研究及其对假体设计与植入的影响

目的测量部分国人肱骨近端的三维解剖数据,并与欧美人的解剖数据对比,评估假体设计及假体在术中的定位和安装规范对中国人的适用度。方法正常成人志愿者180例,随机选取单侧肩关节,进行CT扫描,扫描层厚5mm,以1.25mm层厚、0.6mm层间隔进行重建,重建后的图像用Mimics与Imageware软件进行处理,进行三维测量。结果国人平均肱骨全长(29.7±1.9)cm,平均肱骨近端髓腔直径(11.6±1.9)mm,平均肱骨头额状面直径(42.4±4.0)mm,平均肱骨头矢状面直径(40.1±3.9)mm,额状面与矢状面直径比为1.06±0.09,平均肱骨头表面曲率直径(44.6±4.4)mm,平均肱骨头高度(16.7±1.9)mm,肱骨头高度与曲率半径比为0.75±0.07,颈干角平均129.7°±4.3°,肱骨头后倾角平均15.9°±9.2°,肱骨头内侧偏心距平均(5.0±1.6)mm,肱骨头后侧偏心距平均(3.5±1.6)mm。与欧美人相比,只有肱骨近端髓腔直径与肱骨头高度比较,差异无统计学意义,与其他项目比较差异有统计学意义,且国人的肱骨头高度、颈干角、后倾角均与目前手术规范有区别。结论国人与欧美人种的肩关节解剖存在很大差异,应对引进假体进行适当改进,并制定假体在术中的定位与安装标志。     

退变腰椎小关节的CT形态学观察

目的：经CT对腰椎小关节退行性变进行扫描观察,总结病理变化。方法：收集88例小关节退变病人的下腰椎CT片,对小关节及相关结构进行观察并记录各种病理变化的发生率。结果：小关节退变病理变化依次为：关节间隙狭窄、软骨下骨疏松或硬化、骨赘形成、关节真空、关节囊钙化、关节面矢向变化、关节突肥大、小关节脱位。结论;经CT观察腰椎小关节结构较为方便可靠;对各种病理变化的总结有利于提高对腰椎退变性病变的认识。     

人工肱骨头置换治疗肱骨近端粉碎性骨折

目的探讨人工肱骨头置换治疗肱骨近端粉碎性骨折的疗效。方法对8例肱骨近端粉碎性骨折(NeerⅣ型)患者行人工肱骨头置换术,术中同时修复受损的肩袖和关节囊,术后患肩早期进行功能锻炼。结果术后随访6～34个月,病人主观满意度为86.5%,肩关节疼痛评分4.6分,主动活动度:平均外展91°、前屈95°、外旋35°、内旋至L2水平,术后三角肌、肩内旋肌、外旋肌力平均为4.5、4.1、4.2分,肩关节功能评分为3.5分。X线片示肱骨头位置良好,无假体松动或断裂。结论对肱骨近端粉碎性骨折,人工肱骨头置换是一种有效的治疗方法,能明显减少术后肩关节疼痛,最大限度恢复其运动功能。     

肱骨近端粉碎骨折锁定钢板与人工肱骨头置换术的对比研究

目的探讨应用肱骨近端锁定钢板和人工肱骨头置换治疗肱骨近端复杂骨折的近期疗效。方法回顾性分析我科自2006年1月至2009年12月期间采用肱骨近端锁定钢板和人工肱骨头置换治疗Neer三、四部分肱骨近端骨折患者37例,行肱骨近端锁定钢板治疗肱骨近端骨折20例,其中Neer三部分骨折14例,四部分骨折6例;人工肱骨头置换治疗肱骨近端骨折17例,均为四部分骨折。采用Neer评分标准从疼痛、活动、功能等方面评定两组疗效。结果平均随访时间为20个月（12～30个月）。内固定组优良率为83．3％,置换组优良率为87．5％,两组比较差异无统计学意义（P〉0．05）。结论锁定钢板与人工肱骨头置换在治疗肱骨近端粉碎骨折均能达到满意的疗效,但对于骨折严重粉碎无法重建的肱骨近端骨折,尤其伴有严重骨质疏松的老年患者,人工肱骨头置换仍是最佳选择。     

Osteonecrosis of the Humeral Head

Current understanding of osteonecrosis of the humeral head is largely based on previous studies of the femoral head. Similarities between the two sites are numerous, but the shoulder has many unique characteristics. The anatomy of the glenohumeral joint, motion at the scapulothoracic joint, the rich vascular supply of the surrounding soft tissues, and the accommodations for the different forces (shear, compression) exerted across the glenohumeral joint all allow the shoulder to tolerate a greater amount of deformity. A number of pathologic agents can cause bone death by disrupting the blood supply, among them corticosteroid use, trauma, dysbarism, hemoglobinopathies, and various systemic diseases that disrupt the vascular system, such as Gaucher's disease and systemic lupus erythematosus. Management is similar to that of femoral osteonecrosis; the earlier stages respond well to nonoperative approaches, and the more advanced stages require surgical intervention. Hemiarthroplasty and total shoulder arthroplasty have produced good outcomes. Surgical intervention with core decompression, vascular flaps, and arthroscopic debridement have also shown promise, but further studies are necessary to define their optimal use.     

Intramedullary Nailing of Humeral Head and Humeral Shaft Fractures

Abstract There is an increasing interest in intramedullary nailing for humeral fractures. Starting with diaphyseal fractures, now also proximal metaphyseal fractures of the humerus can be nailed with satisfying results. Basic ideas for humeral nailing are less invasive approaches to the humerus, less soft tissue damage, e.g. lower rates of radial nerve palsy, closed reduction and the biomechanical aspects of a central implant with elastic fixation properties. Nailing of diaphyseal humeral shaft fractures is an equivalent alternative to plating; nailing of proximal metaphyseal humeral fractures is still new and needs more reliable scientific data to clear its advantages compared to other fixation techniques. Nailing of distal metaphyseal humeral fractures is no serious option at the moment. Angular stable interlocking systems show better fixation qualities for proximal fractures or fracture components. Although in very osteoporotic bone cutouts are registered. Static interlocking is advisable. High torsional stability of the fracture fixation has to be achieved, since significant torsional load occurs during the usual movement of the upper limbs. As there is an important learning curve, possible complications of intramedullary nailing have to be kept in mind and avoided by a careful operation technique.     

Humeral Head Replacement in the Treatment of Comminuted Proximal Humeral Fracture

ObjectiveTo investigate the outcomes of humeral head replacement in the treatment of patients with comminuted proximal humeral fracture.MethodsBetween February 2013 and September 2016, 56 patients underwent humeral head replacement in our hospital. Of them, 18 cases were diagnosed as comminuted proximal humeral fracture before the operation. The mean age of the patients was 69.5 years old (ranging from 61 to 79 years old). Of them, there were six males and 12 females. All the patients in this group had fresh fractures. They were all treated by artificial humeral head replacements. After the prosthesis was fixed by bone cement reliably, the greater or lesser trochanter and prosthesis handle were sutured and fixed firmly. The interval time from injury to operation ranged from 1 to 5 days. The Constant Functional Score, operation time, blood loss, nerve injury, joint dislocation rate, and infection rate were recorded at the final follow‐up. The clinical data of these patients were retrospectively studied. All of the data were recorded in average form.ResultsIn this study, the mean duration of follow‐up was 4 years, ranging from 3 to 6 years. The operation time ranged from 75 to 120 min, with the average of 82 min. The blood loss ranged from 100 to 400 mL, with the average of 210 mL. The mean score of Constant Functional Score was 83.5 ± 3.1. Of them, 14 cases achieved excellent and good (scores of more than 80), and four cases achieved moderate and poor (scores of less than 80). No patient suffered from joint dislocation, unstable joint, or infection after the operation. There were two patients with axillary nerve injury before the operation. However, the function could be recovered within 3–6 weeks after the surgery.ConclusionThe artificial humeral head replacement could be applied for the treatment of patients with comminuted proximal humeral fracture. During the surgery process, the stable structure of shoulder joint could be completely restructured, and the rehabilitation plan should be adjusted reasonably and timely after the operation.     

Hemiarthroplasty for Humeral Head Fractures

Abstract Objective: Replacement of the fractured humeral head with a modular prosthesis. The procedure aims at an adequate reconstruction of shape and function of the shoulder. Indications: Displaced three- and four-part fractures of the proximal humerus that cannot be reduced and internally fixed. Contraindications: Fracture can be reduced and adequately internally fixated. Noncompliant patient. Surgical Technique: In beach-chair position, the fractured humeral head is removed via a deltopectoral approach. The Aequalis modular fracture prosthesis can be positioned by two methods: (i) a fracture jig optimizing height and retroversion of the prosthesis, (ii) under additional intraoperative fluoroscopy. Healing of the tuberosities can be promoted by cancellous grafts taken from the fractured head. These are fixed by four heavy sutures running horizontally and two sutures running vertically. Results: 13 out of 22 patients treated by primary hemiarthroplasty (within 10 days after the fracture) and 34 out of 50 patients treated by secondary arthroplasty could be assessed after a mean follow-up of 40 (15–70) and 44 (8–98) months, respectively. The absolute Constant score amounted to 45 and 50 points, respectively, and the relative score to 56% in both groups. The majority of patients was free of pain or suffered less pain than before the operation (secondary arthroplasty; p < 0.001). In contrast to these, only satisfactory, objective results, self-assessment was good or better than before (secondary prostheses; p < 0.001). In both groups, prognostic factors were the size and position of the tuberosities (p < 0.001). The following is a reprint from Operat Orthop Traumatol 2004;16:1–27 and continues the new series of articles at providing continuing education on operative techniques to the European trauma community. Reprint from: Operat Orthop Traumatol 2004;16:1–27 DOI 10.1007/s00064-004-1091-1     

喙肩韧带切除后肱骨头移位生物力学初步研究

目的通过对成人尸体肩关节的生物力学研究,建立数个基本的肩关节模型,比较喙肩韧带切除前后肱骨头移位情况,以设计验证改良肩峰成形术控制肱骨头移位的方法。方法取新鲜尸体肩关节6例,其中模拟组1例,实验组5例。通过对模拟组建模并操作后,对实验组5例建立相同模型,以未手术、喙肩韧带切除术进行组内及组间比较,并完成统计分析。结果喙肩韧带切除术后肱骨头前上移位显著增大;对冈上肌、冈下肌及肩胛下肌肌力加强后,所有模型肱骨头移位相对减小,其中加强了冈上肌、肩胛下肌肌力的模型肱骨头移位相对最小。结论通过模拟建立的改良肩峰成形术有利于控制喙肩韧带切除后肱骨头移位。     

Wear of the Polyethylene Head of the Oscobal Prosthesis

Ten hemiarthroplasties were performed with the Oscobal (Daubenspeck) hip prosthesis, which consists of a metal stem and a non-rotating polyethylene head. Five patients died 1-150 days after the operation. Signs of massive wear of the polyethylene head were demonstrated in four out of the five patients still alive 16-28 months after the operation. We can therefore not recommend the Oscobal system for hemiarthroplasty of the hip.