髋臼骨折的生物力学及相关研究
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摘要
1髋臼横断骨折不同内固定方法的生物力学研究
目的：髋臼骨折约占全身骨折的3%，长期随访发现手术治疗的远期疗效优于保守治疗，故手术治疗日益普及，内固定方法及内固定种类也越来越多。我们将髋臼横断骨折六种常用的内固定方法进行生物力学比较，现将研究结果报道如下。
方法：取成年男性防腐骨盆标本30个（含双侧股骨上段），将30个骨盆标本自正中矢状面锯开，得半骨盆标本60个，仔细剔除附着的肌肉、韧带、关节囊，肉眼观察及X线摄片均证实无风湿、结核、骨折、肿瘤等病变及解剖学变异，于股骨头、颈交界处截断股骨颈，与传动杆连接。自髂腰肌沟中央到坐骨大切迹与坐骨棘连线中点用手锯截断髋臼，模拟髋臼横断骨折（手锯厚约0.6mm），骨折线平滑，截骨面与人体横断面平行。将60个半骨盆标本随机分为六组，分别按下列方法内固定：A.前柱单钢板；B.后柱单钢板；C.后柱双钢板；D.前柱单钢板加后柱单钢板；E.前柱拉力螺钉加后柱单钢板；F.前柱拉力螺钉加后柱拉力螺钉。各组所用的钢板、螺丝钉之材料，规格完全相同。各组所用的前柱或后柱拉力螺钉之材料，规格亦完全相同。行钢板内固定时要注意以下几点：将骨盆弧形钢板弯曲塑形，使之与骨皮质密切贴合，并使骨折线两侧钢板等长。螺丝钉不可穿透髋关节或穿过骨折线。本实验采用css-44020型生物力学试验机，将标本放在特制的夹具上，使髋臼指向上方。该夹具由两个光滑金属斜面构成，该两金属斜面与水平面呈12.5o角并以155.0o角相交于顶点。将半骨盆标本骶骨断面及耻骨联合断面与金属斜面接触处涂以适量润滑油，以便加载时骶骨断面及耻骨联合断面可向双侧自由滑动。将传动杆与股骨颈断面牢固连接，将股骨头放入髋臼进行垂直加载，本实验采用连续性负载，加载速度为5.00mm/min直至内固定失败，用塞规法测量髋臼关节面的移位。（本实验规定：关节面移位
>3.00mm为内固定失败）记录下内固定失败时各标本的相应负载，采用Stata 4.0统计学软件进行方差分析、Scheffe法检验。
结果：三组标本钢板均无断裂，螺丝钉无拔出，拉力螺钉无折断。传动杆与股骨颈断面连接紧密，无松动及下陷，半骨盆标本无骨折。单柱内固定后，最大移位发生在未行内固定侧，故本实验中前柱内固定者仅测量后柱的移位，后柱内固定者仅测量前柱的移位。对于髋臼横断骨折，前柱单钢板内固定（A组）能承担的最大负载为：520.02±68.46N，后柱单钢板内固定（B组）能承担的最大负载为：308.04±79.32N，后柱双钢板内固定（C组）能承担的最大负载为：837.99±109.68N,前柱单钢板加后柱单钢板内固定(D组)能承担的最大负载为：1024.93±108.77N,前柱拉力螺钉加后柱单钢板内固定(E组)能承担的最大负载为:1022.40±127.67N,前柱拉力螺钉加后柱拉力螺钉内固定(F组)能承担的最大负载为:1121.19±127.17N,该六组数据经Skewness/Kurtosis法正态性检验,均呈正态性分布(偏度及峰度均大于0.1),经Bartlett，s法方差分析，方差齐（X2=5.0827,P=0.406>0.05）,经Scheffe法两两比较,A、B、C三组具有显著性差异(P<0.05),D、E、F三组数据无显著性差异(P>0.05)。采用双柱内固定的D、E、F三组数据均大于采用单柱内固定的A、B、C三组。在采用单柱内固定的A、B、C三组数据中:C组>A组>B组(P<0.05)。在D、E、F三组中,F组内固定强度稍大,但与D、E两组相比无统计学差异（P<0.05）。
结论：双柱内固定的稳定性高于单柱内固定稳定性。在行单柱内固定方法中：后柱双钢板内固定的稳定性高于前柱单钢板内固定，前柱单钢板内固定的稳定性高于后柱单钢板内固定。在双柱内固定的方法中，虽然前柱拉力螺钉加后柱单钢板的稳定性稍强，但与其它两种方法相比无统计学区别。
关键词：髋臼横断骨折;内固定;生物力学
1 Biomechanical Study of Transverse Acetabular Fracture Fixation Methods
Objective: Acetabular fractures are common,representing 3% of all fractures. The majority of authors agree that the clinical results of patients treated surgically are superior to those in patients treated nonoperatively. More and more internal fixation methods had been proposed. The purpose of this study was to evaluate the stability of six kinds of internal fixation methods requiring anterior or posterior surgical approach for the transverse acetabular fracture.
Methods: Thirty embalmed pelves plus the proximal femora were harvested for this study. Each of these thirty pelves was sectioned sagittally through the midline of the sacrum and the symphysis. This produced sixty hemipelves for testing. All of these specimens were visually examined and then X-rayed to exclude the presence of hip pathology. All muscles and connective tissues, including the hip capsule were dissected. An osteotomy which was perpendicular to the femoral neck was made. The femoral head was preserved.The fracture was made by a saw, with a blade thickness of 0.6mm.The osteotomy was directed from the center of the sulcus for the iliopsoas muscle on the anterior acetabular wall, just posterolateral to the iliopectineal eminence toward the junction of the inferior part of the acetabular roof and the cotyloid fossa, toward the midpoint of the greater sciatic notch and the sciatic spina. The fracture plane was parallel to the transverse plane.The osteotomy provided no interdigitation or inherent stability to the fracture site. The sixty hemipelves were divided into six groups randomly. Each group was repaired with one of the six fixation methods. Internal fixation methods consisted of (A) a single anterior column plate, (B) a single posterior column plate, (C) double posterior
column plates, (D) anterior column plate and posterior column plate; (E) anterior column lag screw and posterior column plate, (F) anterior column lag screw and posterior column lag screw.All of the plates, screws and lag screws were the same in material and shape. Attention The midpoint of the plate was on the fracture line. The plates were contoured carefully to fit the surface of the anterior or posterior column. All of the screws must not penetrate the hip joint or interfere with the fracture line.The position of the plates and screws was confirmed by X-ray photography. This biomechanical study was finished by a biomechanical test machine (Model:css-44020,Changchun,China).Each repaired hemipelvis was put on the jig. The acetabular was on the top. The force was applied through the femoral head which was connected to a transition bar. The jig consisted of two metal slopes. There was a 12.5 degree angle between each of the two slopes and the horizontal plane. There was a 155.0 degree angle between these two metal slopes. Then this transition bar was attached to the load cell. This metal bar was perpendicular to the horizontal plane. When the load was applied, the sacrum section and the symphysis section would slide along the metal slopes in an opposite direction. The femoral head was driven into the acetabulum at the speed of 5.00mm/min.The loads were increased in a continuous manner until the internal fixation failed. The internal fixation failure was defined as the gap displacement of the articular surface was more than 3.00mm.This articular surface gap displacement was measured by a plug gauge. The maximal loads were recorded. Differences tested at the P<0.05 level using a repeated measures analysis of variance and Scheffe-test with the help of statistical software-Stata 4.0.
Results: (1)All of the plates were not damaged. All of the screws were not pulled out. The lag screws were not bent. The transition bar was connected to the femoral head tightly. All of the hemipelves did not have fractures. With single column internal fixation, the maximal displacement occurred at the opposite column.(2)To the transverse acetabular fracture, the maximal load for the anterior column plate(Group
目的：髋臼骨折约占全身骨折的3%，长期随访发现手术治疗的远期疗效优于保守治疗，故手术治疗日益普及，内固定方法及内固定种类也越来越多。我们将髋臼横断骨折六种常用的内固定方法进行生物力学比较，现将研究结果报道如下。
方法：取成年男性防腐骨盆标本30个（含双侧股骨上段），将30个骨盆标本自正中矢状面锯开，得半骨盆标本60个，仔细剔除附着的肌肉、韧带、关节囊，肉眼观察及X线摄片均证实无风湿、结核、骨折、肿瘤等病变及解剖学变异，于股骨头、颈交界处截断股骨颈，与传动杆连接。自髂腰肌沟中央到坐骨大切迹与坐骨棘连线中点用手锯截断髋臼，模拟髋臼横断骨折（手锯厚约0.6mm），骨折线平滑，截骨面与人体横断面平行。将60个半骨盆标本随机分为六组，分别按下列方法内固定：A.前柱单钢板；B.后柱单钢板；C.后柱双钢板；D.前柱单钢板加后柱单钢板；E.前柱拉力螺钉加后柱单钢板；F.前柱拉力螺钉加后柱拉力螺钉。各组所用的钢板、螺丝钉之材料，规格完全相同。各组所用的前柱或后柱拉力螺钉之材料，规格亦完全相同。行钢板内固定时要注意以下几点：将骨盆弧形钢板弯曲塑形，使之与骨皮质密切贴合，并使骨折线两侧钢板等长。螺丝钉不可穿透髋关节或穿过骨折线。本实验采用css-44020型生物力学试验机，将标本放在特制的夹具上，使髋臼指向上方。该夹具由两个光滑金属斜面构成，该两金属斜面与水平面呈12.5o角并以155.0o角相交于顶点。将半骨盆标本骶骨断面及耻骨联合断面与金属斜面接触处涂以适量润滑油，以便加载时骶骨断面及耻骨联合断面可向双侧自由滑动。将传动杆与股骨颈断面牢固连接，将股骨头放入髋臼进行垂直加载，本实验采用连续性负载，加载速度为5.00mm/min直至内固定失败，用塞规法测量髋臼关节面的移位。（本实验规定：关节面移位
>3.00mm为内固定失败）记录下内固定失败时各标本的相应负载，采用Stata 4.0统计学软件进行方差分析、Scheffe法检验。
结果：三组标本钢板均无断裂，螺丝钉无拔出，拉力螺钉无折断。传动杆与股骨颈断面连接紧密，无松动及下陷，半骨盆标本无骨折。单柱内固定后，最大移位发生在未行内固定侧，故本实验中前柱内固定者仅测量后柱的移位，后柱内固定者仅测量前柱的移位。对于髋臼横断骨折，前柱单钢板内固定（A组）能承担的最大负载为：520.02±68.46N，后柱单钢板内固定（B组）能承担的最大负载为：308.04±79.32N，后柱双钢板内固定（C组）能承担的最大负载为：837.99±109.68N,前柱单钢板加后柱单钢板内固定(D组)能承担的最大负载为：1024.93±108.77N,前柱拉力螺钉加后柱单钢板内固定(E组)能承担的最大负载为:1022.40±127.67N,前柱拉力螺钉加后柱拉力螺钉内固定(F组)能承担的最大负载为:1121.19±127.17N,该六组数据经Skewness/Kurtosis法正态性检验,均呈正态性分布(偏度及峰度均大于0.1),经Bartlett，s法方差分析，方差齐（X2=5.0827,P=0.406>0.05）,经Scheffe法两两比较,A、B、C三组具有显著性差异(P<0.05),D、E、F三组数据无显著性差异(P>0.05)。采用双柱内固定的D、E、F三组数据均大于采用单柱内固定的A、B、C三组。在采用单柱内固定的A、B、C三组数据中:C组>A组>B组(P<0.05)。在D、E、F三组中,F组内固定强度稍大,但与D、E两组相比无统计学差异（P<0.05）。
结论：双柱内固定的稳定性高于单柱内固定稳定性。在行单柱内固定方法中：后柱双钢板内固定的稳定性高于前柱单钢板内固定，前柱单钢板内固定的稳定性高于后柱单钢板内固定。在双柱内固定的方法中，虽然前柱拉力螺钉加后柱单钢板的稳定性稍强，但与其它两种方法相比无统计学区别。
关键词：髋臼横断骨折;内固定;生物力学
1 Biomechanical Study of Transverse Acetabular Fracture Fixation Methods
Objective: Acetabular fractures are common,representing 3% of all fractures. The majority of authors agree that the clinical results of patients treated surgically are superior to those in patients treated nonoperatively. More and more internal fixation methods had been proposed. The purpose of this study was to evaluate the stability of six kinds of internal fixation methods requiring anterior or posterior surgical approach for the transverse acetabular fracture.
Methods: Thirty embalmed pelves plus the proximal femora were harvested for this study. Each of these thirty pelves was sectioned sagittally through the midline of the sacrum and the symphysis. This produced sixty hemipelves for testing. All of these specimens were visually examined and then X-rayed to exclude the presence of hip pathology. All muscles and connective tissues, including the hip capsule were dissected. An osteotomy which was perpendicular to the femoral neck was made. The femoral head was preserved.The fracture was made by a saw, with a blade thickness of 0.6mm.The osteotomy was directed from the center of the sulcus for the iliopsoas muscle on the anterior acetabular wall, just posterolateral to the iliopectineal eminence toward the junction of the inferior part of the acetabular roof and the cotyloid fossa, toward the midpoint of the greater sciatic notch and the sciatic spina. The fracture plane was parallel to the transverse plane.The osteotomy provided no interdigitation or inherent stability to the fracture site. The sixty hemipelves were divided into six groups randomly. Each group was repaired with one of the six fixation methods. Internal fixation methods consisted of (A) a single anterior column plate, (B) a single posterior column plate, (C) double posterior
column plates, (D) anterior column plate and posterior column plate; (E) anterior column lag screw and posterior column plate, (F) anterior column lag screw and posterior column lag screw.All of the plates, screws and lag screws were the same in material and shape. Attention The midpoint of the plate was on the fracture line. The plates were contoured carefully to fit the surface of the anterior or posterior column. All of the screws must not penetrate the hip joint or interfere with the fracture line.The position of the plates and screws was confirmed by X-ray photography. This biomechanical study was finished by a biomechanical test machine (Model:css-44020,Changchun,China).Each repaired hemipelvis was put on the jig. The acetabular was on the top. The force was applied through the femoral head which was connected to a transition bar. The jig consisted of two metal slopes. There was a 12.5 degree angle between each of the two slopes and the horizontal plane. There was a 155.0 degree angle between these two metal slopes. Then this transition bar was attached to the load cell. This metal bar was perpendicular to the horizontal plane. When the load was applied, the sacrum section and the symphysis section would slide along the metal slopes in an opposite direction. The femoral head was driven into the acetabulum at the speed of 5.00mm/min.The loads were increased in a continuous manner until the internal fixation failed. The internal fixation failure was defined as the gap displacement of the articular surface was more than 3.00mm.This articular surface gap displacement was measured by a plug gauge. The maximal loads were recorded. Differences tested at the P<0.05 level using a repeated measures analysis of variance and Scheffe-test with the help of statistical software-Stata 4.0.
Results: (1)All of the plates were not damaged. All of the screws were not pulled out. The lag screws were not bent. The transition bar was connected to the femoral head tightly. All of the hemipelves did not have fractures. With single column internal fixation, the maximal displacement occurred at the opposite column.(2)To the transverse acetabular fracture, the maximal load for the anterior column plate(Group
引文
1 Rowe CR , Lowell JD. Prognosis of Fractures of the Acetabulum. J Bone Joint Surg (Am) , 1961,43（1）:30~59
2 Heeg M. Conservative treatment of Acetabular Fractures: The Role of the Weight-bearing Dome and Anatomic Reduction in the Ultimate Results. J Trauma, 1987, 27（5）: 555~559
3 Letournel E .Acetabulum fractures classification and management. Clin Orthop, 1980, 151: 81~97
4 Matta JM. Immediate and lone-term results of surgical treatment of acetabular fractures. Presented at the 1st International Symposium on Surgical Treatment of Acetabular Fractures. Paris France. May 1993
5 沈忆新，郑祖根，徐又佳等.切开复位内固定治疗髋臼骨折. 中华骨科杂志，1995,15（8）：505~506
6 Matta JM, Merritt PO. Displaced Acetabular Fractures. Clin Orthop, 1988, 230: 83~97
7 Matta JM, Mehne DK, Roofi R. Fractures of the acetabulum. Clin Orthop,1986, 205: 241~250
8 Pray TJ, Esser M, Fulkerson L. Osteotomy of the trochanter in open reduction and internal fixation of acetabular fractures. J Bone Joint Surg (Am), 1987, 69:711~717
9 Springer ER, Lachiewicz PF, Gilbert JA. Internal fixation of femoral neck fractures: a comparative biomechanical study of knowles pins and 6.5mm cancellous screws. Clin Orthop, 1991, 267: 85~92
10 Judet R, Judet J, Letournel E. Fractures of the acetabulum: classification and surgical approaches for open reduction. J Bone Joint Surg(Am),1964, 46:1615~1646
11 David L. Helfet, Grarg S. Bartlett. Acetabular fractures, evaluation/classification/treatment concepts and approaches. In: Thomas P. Rüedi, William M. Murphy. Eds. AO principles of fractures management. New York: Thieme Stuttgart 2000, 417~418
12 Nachshon Shazar, Robert J. Brumback, Vincent P. Novak et al. Biomechanical Evaluation of Transverse Acetabular Fracture Fixation. Clin Orthop, 1998, 352: 215~222
13 Pantazopoulos T, Mousafiris C. Surgical treatment of central acetabular fractures. Clin Orthop, 1989, 246: 57~64
14 Mayo KA. Fratures of the acetabulum. Clin Orthop, 1987, 218: 43~51
15 Elliott R.B. Central fractures of the acetabulum. Clin Orthop ,1956, 7: 189~198
16 Senegas J, Liorzou G, Yates M. Complex acetabular fractures: a transtrochanteric lateral surgical approach. Clin Orthop, 1980, 151:107~121
17 Mears DC, Rubash HE: Techniques of internal fixation. In Mears DC, Rubash HE (eds). Pelvic and Acetabular Fractures. Thorofare .NJ. Slack 1986: 299
18 Charles M. Reinert, Michael J.Bosse, Attila Poka ,et al. A Modified extensile exposure for the treatment of complex or malunited acetabular fractures. J Bone Joint Surg (Am), 1988, 70(3): 329~336
19 Emile Letournel. The treatment of acetabular fractures through the illioinguinal approach. Clin Orthop, 1993, 292:62~76
20 Sawaguchi T, Brown TD, Rubash HE, et al. Stability of acetabular fractures after internal fixation. Acta Orthop Scand, 1984, 55: 601~605
21 Peter T. Simonian, M.L. Chip Routt, Richard M. Harrington, et al. The Acetabular T-Type Fracture. A Biomechanical Evaluation of Internal Fixation.Clin Orthop,1995, 314: 234~240
22 Harnroongroj T. The role of the anterior column of the acetabulum on pelvic stability: a biomechanical study. Injury,1998,29(4): 293 ~296
2 Heeg M. Conservative treatment of Acetabular Fractures: The Role of the Weight-bearing Dome and Anatomic Reduction in the Ultimate Results. J Trauma, 1987, 27（5）: 555~559
3 Letournel E .Acetabulum fractures classification and management. Clin Orthop, 1980, 151: 81~97
4 Matta JM. Immediate and lone-term results of surgical treatment of acetabular fractures. Presented at the 1st International Symposium on Surgical Treatment of Acetabular Fractures. Paris France. May 1993
5 沈忆新，郑祖根，徐又佳等.切开复位内固定治疗髋臼骨折. 中华骨科杂志，1995,15（8）：505~506
6 Matta JM, Merritt PO. Displaced Acetabular Fractures. Clin Orthop, 1988, 230: 83~97
7 Matta JM, Mehne DK, Roofi R. Fractures of the acetabulum. Clin Orthop,1986, 205: 241~250
8 Pray TJ, Esser M, Fulkerson L. Osteotomy of the trochanter in open reduction and internal fixation of acetabular fractures. J Bone Joint Surg (Am), 1987, 69:711~717
9 Springer ER, Lachiewicz PF, Gilbert JA. Internal fixation of femoral neck fractures: a comparative biomechanical study of knowles pins and 6.5mm cancellous screws. Clin Orthop, 1991, 267: 85~92
10 Judet R, Judet J, Letournel E. Fractures of the acetabulum: classification and surgical approaches for open reduction. J Bone Joint Surg(Am),1964, 46:1615~1646
11 David L. Helfet, Grarg S. Bartlett. Acetabular fractures, evaluation/classification/treatment concepts and approaches. In: Thomas P. Rüedi, William M. Murphy. Eds. AO principles of fractures management. New York: Thieme Stuttgart 2000, 417~418
12 Nachshon Shazar, Robert J. Brumback, Vincent P. Novak et al. Biomechanical Evaluation of Transverse Acetabular Fracture Fixation. Clin Orthop, 1998, 352: 215~222
13 Pantazopoulos T, Mousafiris C. Surgical treatment of central acetabular fractures. Clin Orthop, 1989, 246: 57~64
14 Mayo KA. Fratures of the acetabulum. Clin Orthop, 1987, 218: 43~51
15 Elliott R.B. Central fractures of the acetabulum. Clin Orthop ,1956, 7: 189~198
16 Senegas J, Liorzou G, Yates M. Complex acetabular fractures: a transtrochanteric lateral surgical approach. Clin Orthop, 1980, 151:107~121
17 Mears DC, Rubash HE: Techniques of internal fixation. In Mears DC, Rubash HE (eds). Pelvic and Acetabular Fractures. Thorofare .NJ. Slack 1986: 299
18 Charles M. Reinert, Michael J.Bosse, Attila Poka ,et al. A Modified extensile exposure for the treatment of complex or malunited acetabular fractures. J Bone Joint Surg (Am), 1988, 70(3): 329~336
19 Emile Letournel. The treatment of acetabular fractures through the illioinguinal approach. Clin Orthop, 1993, 292:62~76
20 Sawaguchi T, Brown TD, Rubash HE, et al. Stability of acetabular fractures after internal fixation. Acta Orthop Scand, 1984, 55: 601~605
21 Peter T. Simonian, M.L. Chip Routt, Richard M. Harrington, et al. The Acetabular T-Type Fracture. A Biomechanical Evaluation of Internal Fixation.Clin Orthop,1995, 314: 234~240
22 Harnroongroj T. The role of the anterior column of the acetabulum on pelvic stability: a biomechanical study. Injury,1998,29(4): 293 ~296